Every finding on record at Artesia Palms Care Center

Based on observation, interview, and record review, the facility failed to provide services to one of eight sampled residents (Resident 167) with limited range of motion ([ROM] full movement potential of a joint) and mobility concerns by failing to provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) and to apply both hand rolls (soft roll positioned in the palm of the hand and fastened with a strap) and the right elbow extension (straightening) splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) from 12/25/2025 to 1/1/2026. This failure had the potential to result in a decline in ROM to both of Resident 167's arms. Findings:During a review of Resident 167's admission Record, the admission Record indicated Resident 167's diagnoses included Huntington's disease (an inherited brain disorder that affects a person's ability to control their movements, emotions, and thinking), epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), dementia (progressive state of decline in mental abilities), and contractures (stiffening/shortening at any joint that reduces the joint's range of motion) to the right elbow and both hands.During a review of Resident 167's Minimum Data Set ([MDS] a resident assessment tool), dated 3/13/2026, the MDS indicated Resident 167 had no speech, rarely/never expressed ideas and wants, rarely/never understood others, and was severely impaired for daily decision making. The MDS indicated Resident 167 was dependent for hygiene, upper body dressing, lower body dressing, and rolling to both sides in bed. The MDS also indicated Resident 167 had functional ROM limitations in both arms and legs.During a review of Resident 167's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge summary, dated [DATE], the OT Discharge Summary indicated the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) provided a return demonstration of the exercises to the neck and both arms. The OT Discharge Summary indicated recommendations for RNA to place the right elbow extension splint and both hand splints. During a review of Resident 167's physician's orders, dated 1/2/2026, the physician's orders indicated for the RNA to provide PROM to both arms, five times per week as tolerated, and to apply both hand rolls and the right elbow extension splint for four to six hours as tolerated, five times per week.During an interview on 5/26/2026 at 10:14 a.m., with the Director of Rehabilitation (DOR), the DOR stated the purpose of RNA (in general) included to maintain the ROM and mobility achieved while a resident was in therapy and to prevent decline. The DOR stated the purpose of splints included maintaining or increasing ROM and preventing contractures. The DOR stated the purpose of ROM exercises included to maintain a joint's integrity, prevent stiffness, and increase ROM. During an observation on 5/26/2026 at 12:00 p.m., in the resident's room, Resident 167 was lying in bed with the right arm positioned in forearm supination (rotation of the forearm that results in the palm facing upward) and right-hand in a fist.During an observation on 5/27/2026 at 8:46 a.m., in the resident's room, Resident 167 was observed lying in bed with both elbows bent, both forearms in supination, and both hands in a fist.During a concurrent interview and record review on 5/27/2026 at 4:14 p.m., with the DOR, Resident 167's OT Discharge summary, dated [DATE], and the physician's orders, dated 1/2/2026, were reviewed. The DOR stated the RNA program should have started upon the OT's recommendation on 12/24/2025. The DOR stated Resident 167's RNA program for PROM to both arms and application of the right elbow extension splint and both hand rolls did not start until 1/2/2026. The DOR stated Resident 167 could have potentially experienced a decline in ROM without RNA services. During a follow-up interview and record review on 5/29/2026 at 12:22 p.m., with the DOR, the DOR stated Resident 167 did not receive RNA between discharge from OT on 12/24/2025 and start of RNA on 1/2/2026. The DOR stated the DOR was on vacation during Resident 167's transition from OT to RNA. The DOR stated the therapy department designated a therapist (OT 1) to submit the physician's orders for RNA while the DOR was on vacation. The DOR stated OT 1 should have but did not input the physician's order for Resident 167's RNA program.During a concurrent interview and record review on 5/29/2026 at 12:40 p.m., with the Director of Nursing (DON), the DON reviewed Resident 167's OT Discharge summary, dated [DATE], and physician's order for RNA, dated 1/2/2026. The DON stated there was a six-day gap between when Resident 167 was discharged from OT to the start of RNA services. The DON stated Resident 167 could have potentially experienced a decline in ROM without receiving RNA for PROM and application of both hand rolls and the right elbow splint. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, dated 7/2024, the P&P indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.

Based on observation, interview, and record review, the facility failed to follow the manufacturer's specifications (detailed documents outlining the technical requirements, performance standards, and physical characteristics of a product) of a rollator walker (four-wheeled mobility aid with a frame, handlebars, hand brakes, and a built-in seat) for one of five sampled residents for accidents (Resident 13). This failure resulted in Resident 13 experiencing a fall from the rollator walker on 5/27/2026. Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (brain damage due to a loss of oxygen to the area), type 2 diabetes mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and history of falling. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (brain damage due to a loss of oxygen to the area), chronic obstructive pulmonary disease ([COPD] long-term lung disease causing difficulty in breathing), type 2 diabetes mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and history of falling. During a review of Resident 13's Minimum Data Set ([MDS] a resident assessment tool), dated 3/6/2026, the MDS indicated Resident 13 had clear speech, understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated required partial/moderate assistance (helper does less than half the effort) for rolling to both sides, transferring from lying in the bed to sitting at the side of the bed, and walking 10 feet (unit of measure). During a review of Resident 13's Nursing - Fall Risk Observation/Assessment, dated 4/14/2026, the Nursing - Fall Risk Observation/Assessment indicated Resident 13 was assessed as a moderate risk for falls. During a review of Resident 13's PT Treatment Encounter, dated 5/26/2026, the PT Treatment Encounter indicated Resident 13 required stand-by assistance ([SBA] required verbal cues without any physical assistance to perform the activity) for walking 150 feet using the four-wheeled (rollator) walker.During an observation on 5/27/2026 at 2:33 p.m. in front of the facility's Palm Terrace building, Licensed Vocational Nurse 1 (LVN 1) was observed pulling Resident 13 up from a lower position with the rollator walker underneath Resident 13. LVN 1 was observed returning Resident 13 to sit onto the seat of the rollator walker when Licensed Vocational Nurse 2 (LVN 2) arrived next to Resident 13. Resident 13 sat on the seat of the rollator walker with LVN 1 positioned behind the resident, rubbing Resident 13's back, and LVN 2 on Resident 13's left side, checking Resident 13's head. During an interview on 5/27/2026 at 2:34 p.m. with LVN 1 in front of the Palm Terrace building, LVN 1 stated Resident 13 was seated on the chair in the rollator walker and wanted to get soda in the vending machine prior to returning to Resident 13's room. LVN 1 stated she was facing Resident 13 while pushing the rollator walker toward the vending machine when the front wheels got stuck in the gap between the slabs of concrete. LVN 1 stated Resident 13 fell back while sitting in the rollator walker and used the frame of the rollator to prevent Resident 13 from falling completely to the ground. During a concurrent observation on 5/27/2026 at 2:34 p.m. while interviewing LVN 1, Resident 13 denied any dizziness and pain and stated to LVN 2 that he still wanted soda from the vending machine. Resident 13 stood and walked to the vending machine using the rollator walker to obtain a soda. LVN 2 and the Director of Nursing (DON) walked alongside Resident 13 toward the resident's room. During an interview on 5/28/2026 at 8:37 a.m. in the resident's room, Resident 13 was awake and alert while lying in bed. Resident 13's rollator walker was observed next to the bed. Resident 13 did not remember falling from the rollator on 5/27/2026.During an interview on 5/28/2026 at 8:40 a.m. with LVN 1, LVN 1 stated Resident 13 was at risk for falls and was outside on 5/27/2026. LVN 1 stated she convinced Resident 13 to return to the room but wanted a soda prior to returning to the room. LVN 1 stated it was Resident 13's preference to remain seated in the rollator walker while LVN 1 pushed Resident 13 toward the vending machine prior to the fall. During an interview on 5/28/2026 at 9:13 a.m. with LVN 2, LVN 2 stated she thought Resident 13 and LVN 1 were returning to Resident 13's room (on 5/27/2026). LVN 2 walked ahead of Resident 13 and LVN 1 to open the door for them when LVN 2 heard shuffling behind her. LVN 2 stated Resident 13 was already sitting on the rollator walker seat when LVN 2 turned around and did not witness Resident 13's actual fall. LVN 2 stated Resident 13's head, back, and extremities were assessed while seated and stated Resident 13 still wanted soda from the vending machine. LVN 2 stated Resident 13 walked to the vending machine using the rollator walker and then walked to the bedroom with both LVN 2 and the DON for a full body assessment.During an interview on 5/28/2026 at 2:25 p.m. with Physical Therapist 1 (PT 1), PT 1 stated Resident 13 required SBA for transfers and to walk 150 feet using a rollator walker. PT 1 stated the facility provided Resident 13 with a rollator walker to allow Resident 13 to sit when feeling tired. PT 1 stated the rollator walker's brakes should be locked prior to sitting in the rollator walker to prevent movement since it has four wheels. During an interview on 5/28/2026 at 2:42 p.m. with PT 1, PT 1 stated the rollator walker's primary purpose was an assistive device for walking.During a review of the manufacturer's specification for Resident 13's rollator walker titled, Lightweight Rollator, the manufacturer's specification included an important safety notice which indicated, Do not have anyone push you while you are seated on the Rollator. This is a walking aid only and is not to be used as a transportation device.During a concurrent interview and review of the manufacturer's specifications for the rollator walker on 5/29/2026 at 12:04 p.m. with PT 1, PT 1 stated locking the brakes while sitting in the rollator walker was important for safety. PT 1 stated it was not safe for staff to push a resident while sitting in the rollator walker which was also indicated in the manufacturer's specifications for Resident 13's rollator walker. PT 1 stated a resident could fall forward, slip off, or fall back from the rollator walker while being pushed in the rollator walker. During a concurrent interview and review of the manufacturer's specifications for the rollator walker on 5/29/2026 at 12:40 p.m. with the DON, the DON reviewed the manufacturer's specifications for Resident 13's rollator walker and stated that the resident should not be pushed while sitting in the rollator walker since it could lead to falls and injury. During a review of the facility's policy and procedures (P&P) titled, Safety and Supervision of Resident, revised 7/2024, the P&P indicated the facility strives to make the environment as free for accident hazards as possible. The P&P indicated the facility staff shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.

Based on observation, interview, and record review, the facility failed to provide accurate and complete documentation for two of 35 sampled residents (Resident 13 and Resident 46) by failing to:a. Provide accurate documentation of Resident 13's fall which occurred while sitting in a rollator walker (four-wheeled mobility aid with a frame, handlebars, hand brakes, and a built-in seat) on 5/27/2026. b. Determine Resident 46's decision making capacity (the ability to make decisions regarding health care and related treatment choice) upon admission. These failures had the potential to prevent the facility from determining the cause of Resident 13's fall and to prevent additional falls. These failures also had the potential to prevent Resident 46 and/or the responsible party from making decisions regarding Resident 46's care. Findings: a. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (brain damage due to a loss of oxygen to the area), chronic obstructive pulmonary disease ([COPD] long-term lung disease causing difficulty in breathing), type 2 diabetes mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and history of falling. During a review of Resident 13's Minimum Data Set ([MDS] a resident assessment tool), dated 3/6/2026, the MDS indicated Resident 13 had clear speech, understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated required partial/moderate assistance (helper does less than half the effort) for rolling to both sides, transferring from lying in the bed to sitting at the side of the bed, and walking 10 feet (unit of measure). During a review of Resident 13's PT Treatment Encounter, dated 5/26/2026, the PT Treatment Encounter indicated Resident 13 required stand-by assistance ([SBA] required verbal cues without any physical assistance to perform the activity) for walking 150 feet using the four-wheeled (rollator) walker. During an observation on 5/27/2026 at 2:33 p.m., in front of the facility's Palm Terrace building, Licensed Vocational Nurse 1 (LVN 1) was observed pulling Resident 13 up from a lower position with the rollator walker underneath Resident 13. LVN 1 was observed returning Resident 13 to sit onto the seat of the rollator walker when Licensed Vocational Nurse 2 (LVN 2) arrived next to Resident 13. Resident 13 sat on the seat of the rollator walker with LVN 1 positioned behind the resident, rubbing Resident 13's back, and LVN 2 on Resident 13's left side, checking Resident 13's head. During an interview on 5/27/2026 at 2:34 p.m., with LVN 1 in front of the Palm Terrace building, LVN 1 stated Resident 13 was seated on the chair in the rollator walker and wanted to get soda in the vending machine prior to returning to Resident 13's room. LVN 1 stated she was facing Resident 13 while pushing the rollator walker toward the vending machine when the front wheels got stuck in the gap between the slabs of concrete. LVN 1 stated Resident 13 fell back while sitting in the rollator walker and used the frame of the rollator to prevent Resident 13 from falling completely to the ground. During a concurrent observation on 5/27/2026 at 2:34 p.m. while interviewing LVN 1, Resident 13 denied any dizziness and pain and stated to LVN 2 that he still wanted soda from the vending machine. Resident 13 stood and walked to the vending machine using the rollator walker to obtain a soda. LVN 2 and the Director of Nursing (DON) walked alongside Resident 13 toward the resident's room. During a review of Resident 13's Progress Note, dated 5/27/2026 timed at 2:29 p.m., by LVN 1 (unknown date and time entered), the Progress Note indicated Resident 13 had a witnessed fall outside the Palm Terrace building near the vending machine. The Progress Note indicated, During ambulation, resident lifted/picked up the walker.and became unsteady and lost balance while attempting to continue ambulating with the walker improperly positioned. The Progress Note indicated LVN 1 remained in close proximity and immediately intervened, maintaining support of the resident and safety assisting/lowering resident to the floor in a controlled manner to prevent injury. During an interview on 5/28/2026 at 8:37 a.m. , in the resident's room, Resident 13 was awake and alert while lying in bed. Resident 13's rollator walker was observed next to the bed. Resident 13 did not remember falling from the rollator on 5/27/2026. During an interview on 5/28/2026 at 8:40 a.m., with LVN 1, LVN 1 stated Resident 13 was at risk for falls and was outside on 5/27/2026. LVN 1 stated she convinced Resident 13 to return to the room but wanted a soda prior to returning to the room. LVN 1 stated it was Resident 13's preference to remain seated in the rollator walker while LVN 1 pushed Resident 13 toward the vending machine prior to the fall. LVN 1 reviewed Resident 13's Progress Note and stated the Progress Note was inaccurate. LVN 1 stated Resident 13 fell from the seat while LVN 1 was pushing the rollator walker toward the vending machine and stated the rollator walker's wheels became caught in the gap between the slabs of concrete. LVN 1 stated documentation in the medical record should be accurate. LVN 1 stated Progress Note regarding Resident 13's fall needed modification because LVN 1 felt overwhelmed while documenting. During a concurrent interview and record review on 5/29/2026 at 10:27 a.m., with the DON, Resident 13's Progress Note, dated 5/27/2026 timed at 2:29 p.m., was reviewed. The DON stated (in general) a person could more accurately explain an incident at the time of the event due to the recency of the event. The DON stated LVN 1 reported that Resident 13 had a witnessed fall when the wheel of the rollator walker was caught in the gap of the concrete which caused an imbalance. The DON stated Resident 13's Progress Note indicated Resident 13 fell while walking. The DON stated the purpose of medical records (in general) was to keep an account of what happens to a resident while in the facility. The DON stated medical records should include facts to have a full understanding of an incident for resident safety. The DON stated the purpose of documenting a resident's fall incident included recording what occurred during the time of the fall to determine how to prevent the fall in the future. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 1/2026, the P&P indicated documentation in the medical record will be objective, complete, and accurate. b. During a review of Resident 46's admission Record, the admission Record indicated Resident 46 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 46's MDS, dated [DATE], the MDS indicated Resident 46 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, personal and oral hygiene, and toileting, and required supervision for bathing and dressing. During a concurrent interview and record review on 5/29/2026 at 9:09 a.m., with the MDS nurse (MDSN) 1, Resident 46's History & Physical (H&P) dated 4/12/2025, H&P dated 4/22/2026, and Psychiatry (medical specialty in treating mental illness) note dated 4/15/2026 at 10:25 p.m. were reviewed. MDSN 1 stated Resident 46's H&P dated 4/12/2025 and H&P dated 4/22/2026 indicated to defer (decision making) capacity to psych. MDSN 1 stated the H&P dated 4/12/2025, the H&P dated 4/22/2026, and the psychiatry noted dated 4/15/2026 did not indicate whether Resident 46 had the capacity to make decisions or not. MDSN 1 stated Resident 46 was stable and alert and remembered things. MDSN 1 stated the facility referred to the H&P to determine if a resident (general) had the ability to make medical decisions for themselves. MDSN 1 stated if health care decision making capacity is not determined by a physician, there is a risk of not respecting the resident's preferences or potentially violating their right to make their own decisions. During a concurrent interview and record review on 5/29/2026 at 10:06 a.m., with the Social Services Director, Resident 46's H&P dated 4/12/2025, H&P dated 4/22/2026, Psychiatry note dated 4/15/2026 at 10:25 p.m., and Psychiatry note dated 4/15/2026 at 10:42 a.m. were reviewed. The SSD stated the Psychiatry note dated 4/15/2026 at 10:42 a.m. indicated that Resident 46 did not possess medical decision-making capacity was created and entered by the psychiatry provider on 5/29/2026 at 10:43 a.m. The SSD stated prior to the psychiatry note dated 4/15/2026 at 10:42 a.m. created on 5/29/2026 at 10:43 a.m., there was no documentation by the facility that indicated Resident 46's decision making capacity was determined. The SSD stated social services and nursing should have followed up when the H&P stated defer capacity to psych. The SSD stated Resident 46's health care decision making capacity should have been determined at the time of admission. During an interview on 5/29/2026 at 12:19 p.m., with the Director of Nursing (DON), the DON stated decision making capacity was determined by physicians and was document in the H&P at the time of admission. The DON stated if decision making capacity was not determine by the physician, there is a potential for a delay of care. The DON stated the decision making capacity should be determined and documented on the H&P as soon as possible after the resident is admitted . During a review of the facility's P&P, titled Decision Making Capacity, revised March 2026, the P&P indicated The physician (or licensed mental health provider – psychiatrist, psychologist) will determine the resident's capacity to consent to medical care upon admission. During a review of the facility's P&P, titled Charting and Documentation, revised January 2026, the P&P indicated Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to ensure facility staff accurately documented in the clinical record for one of five sampled residents (Resident 1) when Resident 1 had multiple prior attempts to elope (an unauthorized departure of a patient from an around-the-clock care setting) from the facility, but documentation indicated he did not attempt to elope.This failure of inaccurate documentation posed a risk for staff not identifying Resident 1 as an elopement risk, which could delay timely interventions and place Resident 1 at risk for injury or death due to unsupervised exit from the facility.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dementia (a progressive state of decline in mental abilities) and generalized anxiety disorder (a mental health condition where a person experiences excessive, persistent worry or fear that is out of proportion to the situation and hard to control, interfering with daily life).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/21/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) from staff for his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 9/14/2025 and timed at 7:03 a.m., the SBAR indicated Resident 1 was observed attempting to jump over a facility fence. Facility staff (unknown) immediately approached Resident 1 and redirected him away from the area.During a review of Resident 1's Elopement and Wandering Risk Observation/Assessment form dated 9/14/2025 and timed at 11:10 a.m., the form indicated Registered Nurse Supervisor (RNS) 1 documented in the History of Elopement Attempts section (Section F) that Resident 1 expressed he planned to leave the facility but had not attempted to do so. RNS 1 did not document in Section F that Resident 1 had made one or more elopement attempts within the past year, as Resident 1 had attempted to elope earlier that day (9/14/2025). During a review of Resident 1's Elopement and Wandering Risk Observation/Assessment form dated 9/29/2025, the Minimum Data Set Coordinator (MDSC) documented in the History of Elopement Attempts (Section F) that Resident 1 expressed he planned to leave the facility but had not attempted to do so. The MDSC did not document in Section F that Resident 1 had made one or more elopement attempts within the past year, as Resident 1 had attempted to elope on 9/14/2025.During a review of Resident 1's SBAR dated 11/02/2025 and timed at 2:25 a.m., the SBAR indicated Resident 1 was observed attempting to elope by trying to climb over a facility fence behind the east building. The SBAR indicated Resident 1 was attempting to use a bedside table (a mobile, height-adjustable C or H shaped table designed to roll under and over beds and chairs) to assist him in climbing the fence. The SBAR indicated Certified Nursing Assistant (CNA) 1 immediately intervened, redirected Resident 1 to his room, and removed the bedside tables from the area.During a review of Resident 1's Elopement and Wandering Risk Observation/Assessment form dated 11/2/2025 and timed at 8:51 a.m., the Assistant Director of Nursing (ADON) documented in the History of Elopement Attempts (Section F) that Resident 1 expressed he planned to leave the facility but had not attempted to do so. The ADON did not document in Section F that Resident 1 had made one or more elopement attempts within the past year, as Resident 1 had attempted to elope on 9/14/2025 and on 11/2/2025.During a review of Resident 1's Elopement and Wandering Risk Observation/Assessment form dated 11/17/2025, RNS 1 documented in the History of Elopement Attempts (Section F) that Resident expressed he planned to leave the facility but had no attempted to do so. RNS 1 did not document in Section F that Resident 1 had made one or more elopement attempts within the past year, as Resident 1 had attempted to elope on 9/14/2025 and on 11/2/2025.During an interview on 3/18/2026 at 12 p.m., the Director of Nursing (DON) stated Resident 1's Elopement and Wandering Risk Observation/Assessment forms were completed incorrectly. The DON stated after Resident 1's first elopement attempt on 9/14/2025, the facility staff should have accurately indicated on the Elopement and Wandering Risk Observation/Assessment forms dated 9/14/2025, 9/29/2025, 11/2/2025, 11/17/2025, and 11/21/2025 Resident 1's actual attempt to elope by jumping over a fence and indicating prior attempts. The DON stated the assessment forms documented by facility staff provided an inaccurate depiction of Resident 1's history.During a review of the facility's policy and procedure (P&P) titled Charting and Documentation, dated 1/2026, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

Based on observations, interviews and record review, the facility failed to ensure:26 residents on pureed diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) received pureed textured bread a form that meets their needs and in accordance with the international Dysphagia Diet Initiative-level 4 (IDDSI -a framework made up of levels and describes food textures and drink thickness) level Four (pureed foods and extremely thick drinks) when the texture of the pureed bread was lumpy and liquid seeping out, not smooth and had small pieces of bread crust present requiring chewing before swallowing.This failure had the potential to result in meal dissatisfaction and increased choking risk for 26 out of 166 residents who received the pureed bread from the facility kitchen.Findings:During an observation of the tray line (tray line- a system of food preparation, in which trays move along an assembly line) service for lunch on 12/8/2025 at 11:52AM, the pureed bread looked lumpy, and milk floating on top while in a pan on the steam table.During the same observation and interview with [NAME] (cook2) indicaon 12/8/2025 at 11:52AM, Cook2 stated the pureed bread is bread mixed with milk and blended a little, it is like bread soaked in milk.During a concurrent interview and taste test of the pureed bread with Dietary Supervisor (DS), Registered Dietitian (RD1) and Registered Dietitian (RD2) on 12/8/2025 at 1:45PM, the pureed bread had a lumpy texture. There were small pieces of bread in the pureed bread and bread residue stayed in the mouth. DS stated the consistency of the pureed bread is not smooth and some bread stays in the mouth; DS stated the bread needs a little more blending. DS stated residents on pureed diet can have difficulty swallowing and need to drink liquid to clear the mouth.During an interview with Cook2 on 12/8/2025 at 2:00PM, cook2 stated cook 2 did not blend the bread as long as the other pureed foods. Cook2 stated the bread was mixed with milk and blended so it's soft. Cook2 stated sliced white bread was used to make the pureed bread. Cook2 stated the pureed bread is not smooth because it was not blended long time.During a review of the facility recipe titled Pureed (IDDSI Level 4)Breads, cakes, cookies, pancakes and other bread products (dated 2025) the recipe documented, puree bread on low speed adding milk gradually.the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep.During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline documented that Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of eight sampled residents (Resident 154). This deficient practice had the potential for a delay of care for Resident 154. Findings: During a review of Resident 154's admission Record, the admission Record documented Resident 154 was admitted to the facility 5/12/2010 with diagnoses including Parkinson's disease (a movement disorder of the nervous system that worsens over time) and quadriplegia (unable to move all four limbs). During a review of Resident 154's communication care plan dated 7/24/2025, the care plan documented Resident 154 had altered communication as evidenced by: hearing problem, problems with making self understood, no speech, problem understanding others, dementia (severe cognitive decline affecting memory, thinking, language, and problem-solving). The goal of the care plan was to ensure Resident 154's needs would be met daily. Interventions of the care plan included keeping the soft touch call light (a button is activated with a very light touch which then alerts the caregiver that assistance is needed) with in reach at all times. During a review of Resident 154's Minimum Data Set (MDS, a resident assessment tool) dated 10/9/2025, the MDS documented Resident 154 was severely impaired in daily decision making and never or rarely made decisions. The MDS documented Resident 154 was dependent (helper does all of the effort) for all activities of daily living (ADLs, self-care tasks like bathing, dressing, eating, using the toilet, and moving around, essential for independence). During an observation on 12/8/2025 at 10:25 a.m., Resident 154's soft touch call light (a call light that requires minimal touch to operate) was hanging over Resident 154's tube feeding pump (a medical device that is used to deliver nutrients directly into the gastrointestinal (GI) tract of a patient who is unable to take food or liquids orally) at the side of her bed and not within reach of Resident 154. During an interview on 12/11/2025 at 11:37 a.m., the Director of Nursing (DON) stated a soft touch call light was used for residents that are not able to traditionally call for help using a regular call light. The DON stated the soft touch call light was very sensitive so when it is within resident reach it will activate at the slightest movement to indicate to the staff the resident may need assistance. The DON stated the soft touch call light handing over the tube feeding pump defeated the purpose because it would not pick up the residents movement. The DON stated it was important to ensure call lights were within reach for safety and to ensure residents had access to assistance when needed. During a review of the facility's policy and procedure (P&P) titled Answering the Call Light dated 10/2010, the P&P documented when the resident was in bed be sure the call light was within easy reach of the resident.

Based on interview and record review, the facility failed to ensure psychotropic medication (medications that affect brain activities associated with mental processes and behavior) was not used unnecessarily for one of three sampled residents (Resident 7) by failing to define and monitor resident specific, measurable target behaviors related to the use of Seroquel [an atypical antipsychotic that's used to improve mood, thoughts, and behaviors for people with schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)] For Resident 7.The deficient practice of failing to ensure an antipsychotic medication was used to treat a specific, diagnosed condition, and failing to monitor target behaviors related to the use of psychotropic medication increased the risk that Resident 7 could have experienced adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.Findings:During a review of Resident 7's admission Record, the admission Record documented, Resident 7 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 7's Psychiatric Follow up Note, dated 11/26/2025, the Psychiatric Follow up Note documented, Resident 7 had limited judgement and insight (understanding) and was oriented to person only.During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 8/27/2025, the MDS documented Resident 7 required maximal assistance (Helper does more than half the effort) from one staff for dressing, shower, moderate assistance (Helper does less than half the effort) from one staff for hygiene, and supervision or touching assistance (Helper provides verbal cues and /or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for bed mobility, eating, transfer. During a review of Resident 7's Order Summary Report, dated 12/10/2025, the Order Summary Report documented, give one tablet Seroquel 50 milligram (mg) by mouth at bedtime for schizoaffective disorder manifested by delusional thoughts/difficulty to redirect was ordered on 6/5/2025.During a concurrent interview and record review on 12/10/2025, at 10:38 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 7's Medication Administration Record (MAR), dated from 9/2025 to 12/2025 was reviewed. The MAR documented, to monitor behavior episodes for Seroquel (antipsychotic [mediation that affects the brain]) use related to schizoaffective disorder, manifested by delusional (having false or unrealistic beliefs) thoughts and difficulty to redirect. The MAR documented, Resident 7 had behavior episodes of delusional thoughts/ was difficult to redirect on 9/28/2025 (two episodes), 9/30/2025 (two episodes), 10/3/2025 (two episodes), 10/10/2025 (2 episodes), 11/1/2025 (one episode), 11/4/2025 (one episode), 11/5/2025 (one episode), 11/6/2025 (two episodes), and 11/9/2025 (one episode). RNS 2 stated, she was not sure what delusional thoughts Resident 7 had. RNS 2 stated, difficulty redirecting could be caused by dementia related behavior. RNS 2 stated, target behavior should be specific and measurable, so the psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) could refer to and consider Gradual Dose Reduction (GDR- a systematic approach to stepwise tapering of medication dosage to assess if a lower dose can effectively manage symptoms, conditions, or risks, or if the medication can be discontinued entirely). RNS 2 stated, staff should monitor specific target behaviors. During a phone interview on 12/10/2025, at 4:09 p.m., with Psychiatric Nurse Practitioner (PNP)1, PNP 1 stated, he ordered Seroquel for schizophrenia (a mental illness that is characterized by disturbances in thought) manifested by paranoia (an irrational and intense distrust or suspicion of others, believing they intend to harm you, even without evidence) thoughts that people want to harm him (Resident 7). PNP 1 stated, he did not know why the staff were monitoring delusional thoughts and difficulty to redirect as target behaviors. PNP 1 stated, those are not resident specific target behaviors. PNP 1 stated, he disagreed with doing a GDR on 11/2025, because there are many behavioral episodes reported in the months of November. PNP 1 stated, he realized the staff were monitoring the wrong target behaviors. PNP 1 stated, Seroquel could be an unnecessary medication, and considered a chemical restraint (the use of medications to restrict a person's movement or freedom of action, or to control behavior, when the medication is not part of a standard treatment for their condition). PNP 1 stated the Seroquel should be tapered down as soon as possible to avoid adverse reaction (an undesired or harmful effect of a drug) and chemical restraint (the use of medications to restrict a person's movement or freedom of action, or to control behavior, when the medication is not part of a standard treatment for their condition).During an interview on 12/10/2025, at 11:25 a.m., with the Director of Nursing (DON), the DON stated, target behavior should be specific and measurable to the resident's diagnosis. The DON stated, delusional thoughts could be many things, and this should be clarified with PNP 1. The DON stated, monitoring specific target behavior was important, because GDR would be performed based on this data. The DON stated, inaccurate data would lead to delays in treatment, and the resident continuing to receive unnecessary medication. The DON stated, the resident might suffer from unnecessary side effects/adverse reactions. The DON stated, unnecessary medication could be used as chemical restraint as well.During a review of Resident 7's, Psychiatric Follow- up Notes, dated on 7/30/2025, 8/31/2025, 9/28/2025,10/26/2025,11/26/2026 documented by PNP 1, the Psychiatric Follow- up Notes documented, Seroquel 50 milligram (mg) at bedtime for schizophrenia manifested by paranoia thoughts that people want to harm him (Resident 7).During a review of Resident 7's, Note to Attending Prescriber for GDR, dated 11/24/2025, the Note to Attending Prescriber for GDR documented, PNP 1 responded to the GDR request by marking Disagree on 11/24/2025.During a review of Resident 7's, Order Summary Report, dated 12/10/2025, the Order Summary Report documented, monitor behavior episodes of antipsychotic use (Seroquel) related to schizoaffective disorder manifested by delusional thoughts/difficulty to redirect was ordered on 7/25/2025.During a review of the facility's Policy and Procedure (P&P) titled, Psychoactive / Psychotropic Medication Use, dated 1/2025, the P&P documented, Policy Interpretation and Implementation: 1. General Guidelines: b. Residents will only receive Psychotropic medications when necessary to treat a specifically diagnosed condition that is documented in the medical record. c. The Attending Physician and other staff will gather and document information to clarify, as possible, the resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. d. The Attending Physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, medical symptoms that may warrant the use of Psychotropic medications.

Based on interview and record review, the facility failed to ensure minimum data set (MDS a resident assessment tool) assessments were coded accurately for two of 35 sampled resident (Resident 2 and Resident 20). -The facility failed to ensure Resident 20 who has a diagnosis of diabetes mellitus (DM a condition where the body can not process sugar normally and may lead to poor wound healing) was coded accurately.-The facility failed to ensure Resident 2's treatment for DM was coded accurately. These failures had the potential for Resident 2 and Resident 20 not receiving an individualized plan of care based on the resident's specific needs and treatment.a.During a review of Resident 20's admission Record, the admission Record documented Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of DM, hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 20's Order Summary Report, dated 5/24/2025, the Order Summary Report documented a physician order for Novolin Flex-pen (a convenient, prefilled insulin [medication used to assist the body process sugar] delivery device) 100 unit per milliliter (u/mL, a unit of measurement) solution pen injector inject as per sliding scale (the amount of insulin to be administered changes up or down based on the individual's blood sugar) subcutaneously (under the skin) before meals and at bedtime for DM. During a review of Resident 20's MDS, dated [DATE], the MDS documented Resident 20 was severely cognitively (thinking process) impaired, and required supervision (helper provides verbal cues and/or touch assistance) with self-care abilities such as eating, hygiene, bathing and putting on clothes and required supervision with mobility such as sit to stand and transfers. The MDS did not indicate Resident 20 had an active diagnoses of DM, and was receiving insulin injections seven days a week. During a concurrent interview and record review on 12/11/2025 at 9:07 a.m., with the MDS Coordinator (MDSC), Resident 20's admission Record, Order Summary Report dated 5/24/2025, and the MDS dated [DATE] were reviewed. The MDSC stated Resident 20 had a diagnosis of DM and was receiving insulin injections seven days a week. The MDSC stated the MDS was not coded (did not indicate) Resident 20 had DM. The MDSC stated the importance of accurate MDS assessment was that DM was a major diagnosis and Resident 20 was receiving medication for the diagnosis. The MDSC stated the MDS should reflect the current medical status of the resident, it should coincide with his diagnosis and the medication he was receiving. During a concurrent interview and record review on 12/11/2025 at 11:25 a.m., with the Director of Nursing (DON), Resident 20's MDS dated [DATE] was reviewed. The DON stated the MDS assessment was an inaccurate assessment of the resident, and the coding should be accurate. The DON stated the importance of accurate MDS coding was the overall accuracy of what the resident has (diagnosis and care needs), the status of the resident and medical services provided and if it was miscoded, it did not display what the resident had. During a review of the facility's policy and procedure (P/P), titled Resident Assessments, revised January 2024, the P/P documented the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments.all persons who have completed any portions of the MDS resident assessment form must sign the document attesting to the accuracy of such information.information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations and interviews. b. During a review of Resident 2's admission Record, the admission Record documented Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including DM. During a review of Resident 2's MDS dated [DATE], the MDS documented Resident 2's cognition was severely impaired. The MDS documented Resident 2 was receiving insulin injections 7 days a week. During a review of Resident 2's Order Summary Report dated 11/16/2025 to 11/30/2025, the Order Summary Report documented an order of Jardiance (medication to regulate blood sugar levels) oral tablet 25 mg for the treatment of DM. There was no order for insulin injections. During a concurrent interview and record review on 12/11/2025 at 9:35 a.m. with the MDSC, the MDSC stated Resident 2 had a diagnosis of DM and no orders for insulin injections. The MDSC stated Resident 2 had an oral medication for the treatment of diabetes mellitus. The MDSC stated insulin was inaccurately coded on Resident 2's MDS assessment dated [DATE]. During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, revised 1/2024, the P&P documented information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 10) by failing to identify triggers of trauma (a very upsetting or harmful experience that can affect a person's mind or body) and develop individualized interventions for Resident 10.These failures had the potential to result in Resident 10's needs not being met, affecting the residents' mental and physical well being. Findings:During a review of Resident 10's admission record, the admission record documented Resident 10 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and legal blindness (a level of visual impairment that makes it difficult to perform daily tasks, even when using regular glasses, contact lenses, medication, or surgery). The admission record documented, Resident 10 had a public guardian (a government official appointed by a court to protect and manage the personal care, finances, and living arrangements for vulnerable adults).During a review of Resident 10's, History and Physical (H&P), dated 3/26/2025, the H&P documented, Resident 10 was alert and oriented to self, place, and time.During a review of Resident 10's minimum data set (MDS a resident assessment tool), dated 9/30/2025, the MDS documented Resident 10 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating, bed mobility and moderate assistance (Helper does less than half the effort) from one staff for hygiene care, shower, dressing, transfer.During a concurrent interview and record review on 12/10/2025, at 10:38 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 10's Care Plan Report, revised 10/21/2025 was reviewed. The Care Plan Report Focus documented, Resident 10 was at risk for psychosocial/emotional trauma related to history of stressful events or experiences (PTSD). The Care Plan Report Goal documented, Resident 10 will express feelings of safety and security in the environment. The Care Plan Report interventions documented, the staff to help Resident 10 to identify triggers that prompt symptoms. RNS 2 stated, Resident 10's Care Plan Report did not indicate what triggers Resident 10 had. RNS 2 stated, facility staff should identify Resident 10's triggers of PTSD (instead of Resident 10 to identify her own triggers) as Care Plan Report interventions documented. RNS 2 stated, the Care Plan Report interventions were not specific to Resident 10 and did not identify what triggers Resident 10 to experience re-traumatization. RNS 2 stated, it was important to identify the triggers and implement interventions that were individualized according to Resident 10's needs to prevent re-traumatization.During a concurrent interview and record review on 12/10/2025, at 2:04 p.m., with the Social Service Director (SSD), Resident 10's Social Service Initial admission Assessment, dated 3/24/2025 was reviewed. The Social Service Initial admission Assessment documented, Resident 10 was diagnosed with PTSD related to events during homelessness. The Social Service Initial admission did not indicate documentation regarding a PTSD assessment for Resident 10. The SSD stated, Resident 10's public guardian mentioned that Resident 10 was assaulted by her ex-boyfriend. The SSD stated, Resident 10 was concerned with being out on the street, homeless. The SSD stated, the staff should have assessed and identified the triggers of PTSD and the severity of possible re-traumatization from the triggers to prevent recurrent events. The SSD stated, completing the trauma assessment was important, because the resident's care would be different according to the needs from the assessment. The SSD stated, he would refer the resident to the proper services according to the trauma assessment to prevent re-traumatization. The SSD stated, Resident 10's care plan was not person centered because there was no proper assessment done for the trauma.During an interview on 12/11/2025, at 11:25 a.m., with the Director of Nursing (DON), the DON stated, the resident's care plan is the specific resident's plan of care, and it should be implemented as it stated. The DON stated, care plan interventions should be implemented and reevaluated. The DON stated care plan interventions were from IDT meeting and should be implemented to prevent recurrent events or problems.During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 4/2023, the P&P documented, Statement: A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Interpretation and Implementation: 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT) . 6. The comprehensive, person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 7) related to failing to revise and update fall prevention interventions recommended during the Interdisciplinary team (IDT-a group of different experts who work together to help the residents with complex needs) meeting regarding actual fall incidents 8/6/2025 and 8/30/2025 for Resident 7.These failures had the potential to result in Resident 7 and 10's needs not being met, affecting the residents' well-being, and poor patient outcomes.Findings:During a review of Resident 7's admission Record, the admission Record documented, Resident 7 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and history of falls.During a review of Resident 7's, Psychiatric Follow up Note, dated 11/26/2025, the Psychiatric Follow up Note documented, Resident 7 had limited judgement and insight (understanding) and was oriented to person only.During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 8/27/2025, the MDS documented Resident 7 required maximal assistance (Helper does more than half the effort) from one staff for dressing, shower, moderate assistance (Helper does less than half the effort) from one staff for hygiene, and supervision or touching assistance (Helper provides verbal cues and /or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for bed mobility, eating, and transfers. During a concurrent interview and record review on 12/10/2025, at 10:44 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 7's IDT Note, dated 8/7/2025 was reviewed. The IDT Note documented, Resident 7 was found sitting on the floor on the left side of his bed on 8/6/2025 with redness on right upper back. The IDT Note documented, IDT meeting recommended to initiate a care plan for falls, provide proper footwear, bilateral (both) landing mats, continue on falling star program (identify individuals at high risk for falls, using visual cues like yellow gowns, armbands, or door signs to alert staff for extra precautions like bed alarms, closer monitoring, and assistance requests), low bed while in bed resting. RNS 2 stated, all these IDT meeting recommended interventions should be reflected in Resident 7's care plan.During a concurrent interview and record review on 12/10/2025, at 10:50 a.m., with RNS 2, Resident 7's IDT Note, dated 9/2/2025 was reviewed. The IDT Note documented, Resident 7 was found on the floor sitting on his bottom facing the television in the dining room on 8/30/2025. The IDT Note documented, IDT meeting recommended to initiate care plan, continue falling star program for safety measures, place Resident 7 on one-to-one sitter (1:1 sitter- a dedicated staff member assigned to continuously watch a specific high-risk patient in a healthcare setting to prevent falls, self-harm, or harm to others) for safety, and encourage Resident 7 to utilize a wheelchair when tired. RNS 2 stated, all IDT recommended interventions should be reflected in Resident 7's care plan to prevent future incidents of fall.During a concurrent interview and record review on 12/10/2025, at 10:55 a.m., with RNS 2, Resident 7's Care Plan Report, initiated 8/22/2025 and revised 12/8/2025 was reviewed. The Care Plan Report Focus documented, Resident 7 was a high risk for falls. The Care Plan Report Goal documented, Resident 7 will have minimal complications related to falls to extent possible. The Care Plan Interventions documented, place the call light within reach, encourage to participate in activities, encourage to use assistive device during ambulation, evaluate medications for side effects, place floor mats, keep bed in low position, keep personal items frequently used within reach, and provide proper footwear. RNS 2 stated, the care plan interventions did not include: the falling star program, the 1:1 sitter, the wheelchair use, and initiate/revise the care plan for actual fall. RNS 2 stated, the staff should initiate or revise the care plan after the actual fall incident of 8/30/2025. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 4/2023, the P&P documented, Statement: A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Interpretation and Implementation include: 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT) . 6. The interdisciplinary team should review and update the care plan: a. When there has been a significant change in the resident's condition . c.At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to ensure monitoring orders were completed and documented as 'complete' as ordered by the physician for one of 35 sampled resident (Resident 47).This deficient practice had the potential to result in unmet medical needs and increased risk of adverse health outcomes for Resident 47.Findings: During a review of Resident 47's admission Record, the admission Record documented Resident 47 was admitted to facility on 2/25/2025 and readmitted on [DATE] with diagnoses including hypertension (high blood pressure), dysphagia (difficulty swallowing), type 2 diabetes (a condition where the body does not use insulin effectively or does not produce enough insulin leading to high blood sugar level) and a history of falling.During a review of Resident 47's Minimum Data Det (MDS- a resident assessment tool) dated 9/3/2025, the MDS documented Resident 47's cognition (ability to make decisions of daily living) was severely impaired. The MDS documented Resident 47 needed Setup or clean-up assistance or supervision for activities of daily living such as hygiene, toileting, and getting dressed.During a review of Resident 47's Order Summary Report dated 12/2/2025, the Order Summary Report documented the following orders:- Monitor for bleeding, discolored urine, black tarry (black, sticky shiny indicating blood) stools, sudden severe headache, nausea, vomiting, diarrhea, muscle joint pain, lethargy (feeling weak, tired no energy), bruising, sudden changes in mental status and/or visible signs of shortness of breath, nose bleeds due to antiplatelet (medication to prevent blood clots)- Monitor behavior, document number of episodes of target behavior (continuous calling out without cause) per shift, due to mood stabilizer (Depakote), prescribed for mood disorder manifested by continuous calling out without cause. -Monitor for signs and symptoms of hyperglycemia (high blood sugar level) for diagnosis of type 2 diabetes such as increased thirst and a dry mouth, needing to pee frequently, tiredness, blurred vision, intentional weight loss, recurrent infections such as thrush, bladder infection and skin infection and notify MD immediately every shift for hyperglycemia.-Monitor for signs or symptoms of Hypoglycemia (low blood sugar level) for diagnosis of type 2 diabetes including irritable, confused behavior, moist pale skin, shallow breathing, tremors, sweating and full bounding pulse and notify MD immediately-Monitor/document/report to MD for signs and symptoms of dehydration (occurs when the body uses or loses more fluid than it takes in) including decreased or no urine output, concentrated urine (dark colored urine), strong odor, tenting skin (skin does not return to normal after being pinched) cracked lips, furrowed tongue (grooves or cracks on tongue's surface) new onset confusion, dizziness on sitting/standing, increased pulse (heart rate), headache, fatigue/weakness, dizziness, fever, thirst, recent sudden weight loss, dry sunken eyes every shift.-Monitor pain level every shift-Monitor vital signs (basic measurements of body's essential functions including blood pressure, temperature, pulse, respirations and oxygen level) every shiftDuring a review of Resident 47's Medication Administration Record (MAR) for December 2, 2025, the MAR did not document the above monitoring orders were completed as ordered during the night shift from 11:00 p.m. to 7:00 a.m.During a concurrent interview and record review on 12/11/2025 at 11:30 a.m., with the Director of Nursing (DON), the DON verified the findings and stated that the monitoring orders should be carried out by the licensed nurses as ordered by the physician to prevent delays in care and delivery of appropriate interventions.During a review of the facility's policy and procedure (P&P) titled, Documentation of Medication Administration revised 12/2025, the P&P documented that the Electronic Medication Administration Record (eMAR) will be utilized to ensure accurate and timely documentation of all medication administrations and associated physician-ordered monitoring requirements. The eMAR will clearly reflect monitoring orders prescribed by the physician, including but not limited to vital sign monitoring, behavioral monitoring, and other clinically documented assessments.

Based on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 37) was provided with floor mats on each side of the bed, as ordered by the physician. This failure put Resident 37 at a higher risk for injury in the event of a fall.During a review of Resident 37's admission Record, the admission record documented the facility readmitted Resident 37 on 7/23/2025, with diagnoses including muscle weakness and paranoid schizophrenia (a mental disorder characterized by delusions and auditory hallucinations).During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2025, the MDS documented Resident 37 had moderate cognitive (thought process) impairment and transfers were not attempted due to medical condition.During a review of Resident 37's untitled plan of care revised date 10/21/2025, the care plan documented, (resident) was at risk for falls and injuries due to risk factors: use of psychoactive (medications that affect the mind/brain) drugs, poor safety awareness, impaired mobility, psychiatric (diseases of the mind) conditions: schizophrenia Interventions included, Resident 27 was a high risk for falls with or without injuries and was on the fall prevention program.During an observation on 12/8/2025 at 10:30 a.m., Resident 37 was observed in bed with bed in low position and a floor mat on the right side of the bed, but not the left side.During an observation on 12/9/2025 at 09:31 a.m., Resident 37 was observed in bed with bed in low position and a floor mat on the right side of the bed, but not the left side.During an observation, interview, and concurrent record review with Licensed Vocational Nurse (LVN) 1 on 12/10/2025 at 8:20 a.m., Resident 37 was observed in bed with a floor mat on the right side and not the left side of the bed. LVN 1 stated Resident 3 was a fall risk. LVN 1 reviewed Resident 37's Order Summary Report. The Order Summary Report documented Resident 37 had an order dated 9/23/2025 for, bilateral (both) floor mats for safety and security. LVN 1 stated Resident 37 should have a floor mat on the left side of the bed also. LVN 1 stated the purpose of floor mats is for safety and to prevent injury.During an interview and concurrent record review with the Director of Nursing (DON), Resident 37's medical record was reviewed. The DON stated Resident 37 had an order for bilateral floor mats, and that should have been implemented right away. The DON stated not having the ordered bilateral floor mats could lead to injury related to a fall. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention Program Policy and Procedure, revised 11/10/2025, the P&P documented the facility's goal is to reduce the number of falls with injury in the facility by implementing resident centered care plan interventions.

Based on interview, and record review, the facility failed to Identify and to intervene in one of three sampled residents' (Resident 10) history of trauma (a very upsetting or harmful experience that can affect a person's mind or body) and triggers which may cause re-traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again).This failure had the potential to result in Resident 10 experiencing unnecessary re-traumatization.Findings:During a review of Resident 10's admission record, the admission record documented Resident 10 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and legal blindness (a level of visual impairment that makes it difficult to perform daily tasks, even when using regular glasses, contact lenses, medication, or surgery). The admission record documented, Resident 10 had a public guardian (a government official appointed by a court to protect and manage the personal care, finances, and living arrangements for vulnerable adults).During a review of Resident 10's History and Physical (H&P), dated 3/26/2025, the H&P documented, Resident 10 was alert and oriented to self, place, and time.During a review of Resident 10's Minimum Data Set (MDS-a resident assessment tool), dated 9/30/2025, the MDS documented Resident 10 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating, bed mobility and moderate assistance (Helper does less than half the effort) from one staff for hygiene care, shower, dressing, transfer.During a concurrent interview and record review on 12/10/2025, at 10:38 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 10's Care Plan Report, revised 10/21/2025 was reviewed. The Care Plan Report Focus documented, Resident 10 was at risk for psychosocial/emotional trauma related to history of stressful events or experiences (PTSD). The Care Plan Report Goal documented, Resident 10 would express feelings of safety and security in the environment. The Care Plan Report interventions documented, the staff help Resident 10 to identify triggers that prompt symptoms. RNS 2 stated, Resident 10's Care Plan Report did not indicate what specific the triggers were for Resident 10. RNS 2 stated, the staff should identify Resident 10's triggers of PTSD. RNS 2 stated, the Care Plan Report interventions would not be individualized without identifying what might trigger Resident 10 to experience re-traumatization. RNS 2 stated, it was important to identify the triggers and implement interventions that were individualized according to Resident 10's needs to prevent re-traumatization.During a concurrent interview and record review on 12/10/2025, at 2:04 p.m., with the Social Service Director (SSD), Resident 10's Social Service Initial admission assessment dated [DATE] was reviewed. The Social Service Initial admission Assessment documented, Resident 10 was diagnosed with PTSD related to homelessness. The Social Service Initial admission did not indicate, documentation of a PTSD assessment on Resident 10. The SSD stated, Resident 10's public guardian mentioned Resident 10 was getting assaulted by her ex-boyfriend when she was homeless. The SSD stated, Resident 10 was concerned with being out on the street and homeless. The SSD stated, the staff should have assessed and identified the triggers of PTSD and the severity of possible re-traumatization from the triggers to prevent recurrent events. The SSD stated, completing the trauma assessment was important, because the resident's care would be different according to the needs from the assessment. The SSD stated, he would refer the resident to proper services according to the trauma assessment to prevent re-traumatization.During an interview on 12/11/2025, at 11:25 a.m., with the Director of Nursing (DON), the DON stated, it was important to identify Resident 10's PTSD triggers to prevent re-traumatization and provide the appropriate care. The DON stated, when a resident who has PTSD as a part of their diagnoses was admitted to the facility, the SSD should assess for triggers, and history to prevent re-traumatization. The DON stated re-traumatization would harm Residents' psychosocial well-being.During a review of Resident 10's Behavioral Health Progress Note, dated 12/3/2025, the Behavioral Health Progress Note documented, Resident 10 met the criteria for PTSD. The Behavioral Health Note documented, there was no documentation regarding the triggers of PTSD, and its severity During a review of the facility's Policy and Procedure(P&P) titled, Trauma Informed Care and Culturally Competent Care, revised 8/2025, the P&P documented, Purpose : To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization .General Guidelines: 1. Traumatic events which may affect residents during their lifetime include: a. physical, sexual and emotional abuse .f. forced displacement . 3. For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. 4. Triggers are highly individualized .Resident Assessment: 1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. 2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments . Resident Care Planning: 1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident. 3. Recognize the relationship between past trauma and current health concerns.

Based on observation, interview, and record review the facility failed to ensure 17 of 91 resident rooms' met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms and 100 sq. ft for each single bed resident room.This deficient practice had the potential to result in inadequate provision of safe nursing care, and privacy for the residents.Findings:During a review of the facility's Client Accommodations Analysis form, provided by the facility on 12/9/2025 and revised 12/11/2025, the facility had 17 rooms that measured less than 80 sq. ft. per resident in multi-bedrooms. The residents' rooms were as follows:[NAME] East Unit.Room T1 (4 beds) 305.75 sq. ft. Room T3 (4 beds) 305.25 sq. fl. Room T8 (4 beds) 298.75 sq. fl. Room T10 (5 beds) 360.5 sq. ft. Room T12 (4 beds) 305.25 sq. fl. Room T14 (4 beds) 314.5 sq. ft. Room T15 (4 beds) 314.5 sq. ft. Room T17 (4 beds) 314.5 sq. ft. Room T18 (4 beds) 305.25 sq. ft. Room T20 (4 beds) 305.25 sq. ft.[NAME] Unit.Room T21 (4 beds) 305.25 sq. ft. Room T23 (4 beds) 314.25 sq. ft. Room T27 (4 beds) 314.25 sq. ft. Room T29 (4 beds) 314.5 sq. ft. Room T30 (4 beds) 314.5 sq. fl. Room T32 (4 beds) 314.25 sq. ft. Room T34 (4 beds) 318.25 sq. ft.During observations, from 12/8/2025 through 12/11/2025, the residents residing in these rooms had enough space to move freely inside the rooms. Each resident in the above rooms had beds and side tables with drawers. There was adequate room for the operation and use of wheelchairs, walkers, or canes. Resident room size did not affect the nursing care or privacy provided to the residents.During an interview on 12/11/2025 at 12:25 p.m., the Administrator (ADM) stated the facility was aware 17 rooms did not meet the 80 sq. ft. requirement for multi resident rooms. The ADM stated it was important to ensure each resident had enough space and the staff were able to provide resident care with enough room to move around.During a review of the facility's policy and procedure (P&P) titled, Bedrooms, revised 1/2025, the P&P documented, Policy Interpretation and Implementation: 1. Bedrooms accommodate no more than two residents at a time. 2. Bedrooms measure at least 80 square feet of space per resident in double rooms.3. Each room is designed to provide full visual privacy for each resident and equipped for adequate nursing care.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1, who discovered a resident on the floor, following an unwitnessed fall (8/21/2025), reported the resident's fall and did not place the resident back in bed prior to a licensed nurse's assessment for one of three sampled residents (Resident 1) reviewed for falls. When the facility was made aware of Resident 1's unwitnessed fall, they failed to conduct a neurological (a series of simple tests to see how well your brain, spinal cord, and nerves are working) assessment, per their policy and procedure (P/P) titled, Neurological Assessment (Routine). These deficient practices resulted in a delay in care (assessment, pain management, evaluation) and transfer to a General Acute Care Hospital (GACH) on 8/22/2025 for continued evaluation and treatment. These deficient practices had the potential for unrecognized injuries as well as unrecognized changes in Resident 1's neurological status. Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [involuntary muscle movements]). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was moderately impaired and required moderate assistance (helper does less than half the effort) with activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of the facility's Investigation Binder, dated 8/22/2025 and timed at 12:45 a.m., the Investigation Binder indicated CNA 1 documented, Resident 1 was trying to get into bed, then assisted him back into his bed. Continued Documentation in the Investigation Binder by Licensed Vocational Nurse (LVN) 2 indicated, Resident 1 reported that he rolled out of bed, fell to the floor and then began to get up by himself. Resident 1 reported the assigned CNA (CNA 1) saw him while trying to go back to bed and assisted him. During an interview on 9/16/2025 at 9:50 a.m., Resident 1 stated he rolled off his bed onto the floor, there were no staff was present, but stated a female employee (CNA 1) came in and assisted him back to bed. Resident 1 stated he told another staff (LVN 2) later that afternoon he had fallen. During an interview on 9/17/2025 at 11:18 a.m., the Assistant Director of Nursing (ADON) stated he was not made aware of Resident 1's fall until 5 p.m., on 8/21/2025 when Registered Nurse Supervisor (RNS) 2 reported it to him. The ADON stated he should have conducted a more thorough investigation of Resident 1's unwitnessed fall. During an interview on 9/17/2025 at 1:34 p.m., LVN 2 stated if Resident 1 was assisted back to bed by CNA 1, CNA 1 should have reported it to the supervisor. LVN 2 stated, she was first made aware of Resident 1's fall when Resident 1 informed her at approximately 5 p.m., on 8/21/2025 that he had fallen at 1 p.m., that afternoon (8/21/2025) and she immediately reported it to her supervisor. During a review of the facility's Certified Nurse Assistant (CNA) Job Description, the CNA Job Description indicated, Report all changes in the resident's condition to the Nurse Supervisor/Charge Nurse as soon as practicable. Report all accidents and incidents you observe on the shift they occur. The facility was unable to provide a P/P indicating steps to take when a resident is found on the floor. b. During an interview on 9/17/2025 at 8:11 a.m., LVN 3 stated a neurological check should be done following a resident's fall to monitor and assess for possible cognitive changes in the resident. During a concurrent interview and record review on 9/17/2025 at 10:45 a.m., with the Medical Records Supervisor (MRS), the MRS provided Resident 1's Neurological Assessment, which indicated Resident 1's neurological assessment was not initiated after Resident 1's fall was reported to LVN 2 on 8/21/2025 at 5 p.m., and prior to Resident 1's transfer to the GACH on 8/22/2025. During a concurrent interview on 9/17/2025 at 11:18 a.m., after reviewing Resident 1's Neurological Assessment, the ADON stated Resident 1's neurological status was not assessed after learning he had fallen, but it should have been done. The ADON stated neurological checks were important because they identified abnormalities in the resident's cognitive function which could possibly lead to a stroke (occurs when blood flow to the brain is interrupted) or a bleed in the brain. During an interview on 9/17/2025 at 2:24 p.m., the Director of Nursing (DON) stated a neurological assessment should be initiated after an unwitnessed fall or trauma to the head and one should have been initiated for Resident 1 after learning he had fallen. During a review of the facility's P/P, titled, Neurological Assessment (Routine) dated 1/2025, the P/P indicated the purpose of this procedure is to provide guidelines for conducting a routine neurological assessment to evaluate the resident for small changes over time that may be indicative of neurological injury.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by one of three sampled residents (Resident 1), when Resident 1 punched Resident 2 in the face on 10/31/2025. This deficient practice resulted in Resident 2 sustaining a left periorbital (area around the eye socket) discoloration, discoloration on the bridge (bony, elevated area between the eyebrows and the tip of the nose) of his nose, a left eyebrow skin tear, and a left dorsal (backside) fifth digit (finger) skin tear. Resident 2 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment and was assessed with a mildly depressed nasal bone fracture (a facial injury where the nasal [nose] bones are broken and pushed inward or backward, often causing a noticeable indentation or deformity of the nose) and a left periorbital hematoma (a collection of blood outside of a blood vessel, typically caused by an injury that ruptures the vessel). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), paranoid schizophrenia (the presence of intense paranoid delusions [having false or unrealistic beliefs of persecution and unwarranted suspicion], and hallucinations [sensory experiences like seeing, hearing, or smelling things that aren't real, yet feel very real]), and a generalized anxiety disorder (mental health condition characterized by pervasive worry and fear). During a review of Resident 1's Minimum Datra Set ([MDS] a resident assessment tool), dated 8/13/2025, the MDS indicated Resident 1 had a moderate cognitive (thought process) impairment. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure (when the heart cannot pump enough blood to the body), COPD, paranoid schizophrenia, bipolar disorder (a disorder that causes mood swings ranging from the lows of depression to elevated periods of emotional highs), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment. During a review of Resident 2's Change of Condition Evaluation, dated 10/31/2025 and timed at 12:34 a.m., the COC evaluation indicated Certified Nurse Assistant (CNA) 2 heard an altercation while in the hallway of Resident 1 and Resident 2's shared restroom and witnessed Resident 2 lying on his back, on the floor, with Resident 1 standing over Resident 2. Residents 1 and 2 were separated immediately and put on one-to-one monitoring ([1:1] continuous, close supervision of a resident). The COC Evaluation indicated Emergency Medical Services (911) were called. During a review of Resident 2's Nursing Comprehensive Skin Evaluation/Assessment, dated 10/31/2025 and timed at 1:52 a.m., the Nursing Comprehensive Skin Evaluation/Assessment indicated Resident 2 was observed with the following: 1. Left periorbital discoloration, measuring 7.0 centimeters ([cm] a unit of measurement) by 9.0 cm, with mild redness, localized swelling, and dark purple in color. 2. Nose bridge discoloration, measuring 2.0 cm by 2.0 cm, dark purple in color. 3. Left eyebrow skin tear measuring 0.5 cm by 1.0 cm, presented as a dry scab (protective crust that forms over a wound) with mild redness. 4. Left dorsal fifth digit skin tear, measuring 0.5 cm by 0.5 cm, presented as dry scab with mild redness. During a review of Resident 2's Nurse's Notes, dated 10/31/2025 and timed at 10:28 a.m., the Nurse's Notes indicated Resident 2's physician ordered Resident 2 to be transferred to a GACH for evaluation and treatment related to a physical altercation. During a review of Resident 2's 72 Hours Charting, dated 10/31/2025 and timed at 12:19 p.m., the 72 Hours Charting indicated Resident 2 was transferred to a GACH at approximately 12:15 p.m., for evaluation and treatment. During a review the of the facility's Five Day Follow Up Report, dated 11/4/2025, the Five Day Follow Up Report indicated on interview with Resident 1, Resident 1 stated he was using the restroom when his roommate (Resident 2) opened the door and walked in. Resident 1 stated, I told him to get out but Resident 2 refused to leave the restroom and came towards him (Resident 1). Resident 1 stated at that point he made contact with Resident 2. During a review of the GACH's ED (Emergency Department) Provider Notes, dated 10/31/2025 and timed at 12:48 p.m., the ED Provider Notes indicated Resident 2 presented with eye trauma after he (Resident 2) walked in on his roommate (Resident 1) in the bathroom and was punched by Resident 1. During a review of the GACH's Computerized Tomography ([CT] a type of imaging that uses X-ray techniques to create detailed images of the body) scan without contrast (scan performed without using a contrast agent [specific dye to highlight specific tissues, organs, or blood vessels]), dated 10/31/2025 and timed at 12:38 p.m., of Resident 2's head, the CT scan indicated the following: 1. A mildly depressed nasal bone fracture. 2. A left periorbital hematoma. During an interview on 11/12/2025 at 6:32 a.m., Resident 2 stated Resident 1 was taking too long to use the toilet (Resident 2 unable to provide details). Resident 2 stated Resident 1 punched him (Resident 2) in the face once and pushed him backwards and he (Resident 2) fell back onto the floor. During an interview on 11/12/2025 at 8:55 a.m., the Assistant Director of Nursing (ADON) stated Resident 1 punched Resident 2 in the face after Resident 2 walked in the bathroom while Resident 1 was still using it. The ADON stated Resident 2 sustained skin tears on his left little finger, his left eyebrow, and had facial discoloration. The ADON stated Resident 2 was transferred to a GACH for evaluation and treatment. The ADON stated the altercation between Residents 1 and 2 was considered physical abuse and residents had the right to be free from abuse. During an interview on 11/12/2025 at 9:40 a.m., the Director of Nursing (DON) stated residents have the right to be free from abuse because it can damage the residents' physical and mental wellbeing. The DON stated Resident 2 sustained injuries from the physical altercation between him and Resident 1. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised 1/2025, the P&P indicated residents have the right to be free from abuse and this includes physical abuse. The P&P indicated there was a facility wide commitment to protect residents from abuse from other residents.

Based on interview and record review, the facility failed to ensure one of four sampled residents, who had a history of wandering into other residents' rooms, was free from physical abuse for one of four sampled residents (Resident 233). The facility failed to: 1. Provide Resident 233 with 1:1 (staff member provides dedicated, individualized attention to a single resident) monitoring to prevent him from wandering into Resident 23's room per untitled Care Plan dated 5/12/2025. 2. Implement the facility's policy and procedure (P&P), titled, Resident Rights, dated January 2025, that indicated the facility would protect a resident's right to be free from abuse. As a result of these deficient practices Resident 23 struck Resident 233 on the face. Resident 233 sustained a right cheek abrasion (injury to the skin's surface resulting from friction or impact), orbital (socket of eye that protects the eyeball) discoloration, and a nosebleed. Findings: During a review of Resident 23's admission record, the admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and was readmitted from a general acute care hospital (GACH 1) on 5/20/2025 with diagnoses including schizoaffective disorder (a mental illness that can negatively affect thoughts, mood, and behavior), antisocial personality (mental health condition characterized by a persistent pattern of disregard for the rights of others often leading to reckless or criminal behavior), and amnestic disorder (significant memory loss affecting the ability to recall past events and form new memories that result from substance abuse and brain injury) due to known alcohol dependence and traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head). During a review of Resident 23's Social Service Discharge Summary and Recommendations, for Aftercare note from GACH 1 dated 5/20/2025, the Social Service Discharge Summary and Recommendations for Aftercare indicated Resident 23 had a history of severely physically assaulting a peer because the peer refused to share a lighter (facility unspecified). The Social Service Discharge Summary and Recommendations for Aftercare note indicated Resident 23 stated he suffered from memory loss and remained isolated and guarded (cautious, reserved and untrusting), and exhibited limited ability to tolerate conflict as seen by him striking a peer for bumping into him (facility unspecified). The Social Service Discharge Summary and Recommendations for Aftercare dated 5/20/2025 indicated despite Resident 23 verbalizing a motivation for change, Resident 23 continued to exhibit poor impulse control and minimal responses to provided interventions. The Social Service Discharge Summary and Recommendations for Aftercare note indicated Resident 23 took advantage of his lower functioning peers. During a review of Resident 23's History and Physical (H&P), dated 5/21/2025, the H&P indicated Resident 23 was unable to make medical decisions. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 5/27/2025, the MDS indicated Resident 23's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills were moderately impaired. The MDS indicated Resident 23 required moderate assistance (staff provide less than half the effort) for shower transfer, bathing, dressing the lower body, personal hygiene, required supervision for toileting hygiene, dressing upper body (above waist), chair/bed-to-chair transfer, required set up for oral hygiene, and was independent in eating. The MDS indicated Resident 23 did not have any impairments on the upper (arms/shoulders) and lower (hips/legs) extremities. The MDS indicated Resident 23 always felt lonely or isolated and was feeling down, depressed, or hopeless for several days (two to six days). The MDS indicated Resident 23 had delusions (misconceptions or beliefs that are firmly held, contrary to reality) as a behavior. During a review of Resident 23's Physician's Order Summary Report dated 5/20/2025 - 5/31/2025, the Physician's Order Summary Report indicated the following orders: 1. Hydroxyzine Pamoate (antihistamine [medication used to treat allergies] medication used to treat anxiety) capsule 50 milligram (mg- unit of mass) one tablet by mouth every 12 hours as needed for anxiety disorder for 14 days manifested by (m/b) inability to relax as evidenced by restlessness, dated 5/20/2025 to 6/3/2025. 2. Monitor behavior episodes of anxiety disorder m/b inability to relax as evidenced by restlessness dated 5/20/2025. 3. Olanzapine (medication used to treat mental health condition characterized by severe and persistent disruptions in thought, perception, emotion, and behavior) give 30 mg by mouth at bedtime for schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food, dated 5/20/2025 (discontinued on 5/28/2025). 4. Olanzapine 15 mg tablet to give two tablets by mouth at bedtime for schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food, dated 5/28/2025. 5. Monitor behavior of schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food, dated 5/20/2025. During a review of Resident 23's Medication Administration Record (MAR- record of medications administered to the resident) from 5/1/2025 to 5/31/2025, the MAR indicated the following: 1. Resident 23 had an episode of mood swing on 5/30/2025 and another episode on 5/31/2025 during the day shift (7:00 a.m. to 3:00 p.m.). 2. Resident 23 had two episodes of anxiety disorder m/b inability to relax as evidenced by restlessness on 5/31/2025 during the day shift. 3. Resident 23 had two episodes of depression m/b inability to sleep during the evening shift (3:00 p.m. to 11:00 p.m.). During a review of Resident 233's admission Record, the admission Record indicated Resident 233 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought involving a break with reality, feelings of suspicion and distrust towards others), unspecified dementia (a progressive state of decline in mental abilities) with other behavioral disturbances (pattern of actions that disrupt a person's ability to function), and cognitive communication deficit (trouble participating in conversations). During a review of Resident 233's Physician's Order Summary Report the Physician's Order Summary Report indicated an order for Risperidone (medication use to treat schizophrenia) 3 mg tablet by mouth two times a day for paranoid schizophrenia m/b irritability dated 5/9/2025. During a review of Resident 233's MAR from 5/1/2025 to 5/31/2025, the MAR indicated to monitor Resident 233's episodes of wandering and to document the resident's location every two hours starting 5/12/2025 with a discontinued date of 5/21/2025. During a review of Resident 233's H&P, dated 5/12/2025, the H&P indicated Resident 233 was not capable of making medical decisions. During a review of Resident 233' untitled Care Plan (CP) dated 5/12/2025, the CP indicated Resident 233 was identified at risk for wandering related to communication deficits, dementia, psychotropic and mood-altering medications. The CP indicated the resident wanders aimlessly. The CP interventions included to provide 1:1 supervision, encourage activity participation, encourage social interaction, and redirect resident as needed, initiated on 5/21/2025. During a review of Resident 233's MDS, dated [DATE], the MDS indicated Resident 233's cognitive skills were moderately impaired. The MDS indicated Resident 233 required moderate assistance with activities of daily living (ADLs- toilet transfer, bathing, toileting hygiene, personal hygiene, chair/bed-to-chair transfer) and required supervision for eating and oral hygiene. The MDS indicated Resident 233 did not have any impairments on the upper and lower extremities. The MDS indicated Resident 233 was feeling down, depressed, or hopeless and had little interest or pleasure in doing things for several days. During a record review of Resident 233's Elopement and Wandering Risk Observation/assessment dated [DATE] at 10:50 p.m., the Elopement and Wandering Risk Assessment indicated Resident 233 was disoriented or had periods of confusion and/or impaired attention span. The Elopement and Wandering Risk Assessment indicated Resident 233 exhibited unsafe wandering or elopement attempts but was easily redirected. The Elopement and Wandering Risk Assessment indicated Resident 233 exhibited behaviors of agitation leading to noncompliance to care and mood swings. During a review of Resident 23's Change of Condition (COC) dated 5/31/2025 at 7:46 p.m., the COC indicated Resident 23 had behavioral symptoms (e.g. agitation, psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality]) and was physically aggressive towards a peer (Resident 233), in Resident 23's room. The COC indicated Resident 23 stated he was attacked by another resident (Resident 233) and retaliated by striking the resident back. Resident 23 was sent out to the hospital for further evaluation and treatment. The COC indicated Resident 23's left palm and right hand were noted with redness. During a review of Resident 23's Physician's Order Summary Report, the Physician's Oder Summary Report indicated an order dated 5/31/2-25 for Resident 23 to have a 1:1 observation until transferred to the hospital. During a review of Resident 23's Progress Note dated 5/31/2025 at 10:14 p.m., the Progress Note indicated Resident 23 was transferred to GACH 3 at approximately 9:00 p.m., for a psychological (related to mental or emotional) evaluation as a perpetrator of physical aggression towards peer (Resident 233). During a review of a follow up Progress Note dated 6/3/2025 at 9:00 p.m., the Progress Note indicated Resident 23 was admitted to a behavioral unit at GACH 3 for psychosis and aggressive behavior. During a review of Resident 23's Interdisciplinary Team (IDT- resident's healthcare team consisting of various specialties that share and combine their knowledge and information to create the best possible care plan for the resident) note, dated 6/2/2025 at 10:34 a.m., the IDT noted indicated on 6/2/2025 (date of incident indicated was an error, incident occurred on 5/31/2025) at 6:35p.m., there was an unwitnessed resident-to-resident altercation involving Resident 233. The IDT note indicated Licensed Vocational Nurse (LVN) 7 heard arguing in Resident 23's room, and upon entering the room, LVN 7 observed Resident 23 standing by the footboard of his bed, and Resident 233 was on the floor, leaning on the neighboring nightstand. The IDT note indicated Resident 23 stated Resident 233 went through his door and punched him, so he (Resident 23) punched him (Resident 233) back with a closed fist. During a review of Resident 233's COC dated 5/31/2025 at 10:01p.m., the COC indicated Resident 233 stated he was attacked by another resident in his (Resident 23's) room. The COC indicated the nursing staff arrived and immediately separated the residents to separate rooms and both residents were assessed for injuries. The COC indicated Resident 233 was noted with edema (swelling) on the lip, nose and right cheek and a contusion (bruise, collection of blood outside of the blood vessels, under the skin due to blunt impact) to the right cheek. Resident 233 was offered Tylenol (used to relieve mild to moderate pain) and cold compress for pain. The COC indicated Resident 233 occasionally moaned or groaned, had facial grimacing, was tense, distressed pacing, fidgeting, and had a headache. The COC indicated Resident 233 had a pain level rated 6 out of 10 on a pain rating scale (0- no pain, 3-4 -moderate pain, 5-7 severe pain and 8-10-excruciating pain) on the top of the scalp (skin covering the head) on the side of the head. The COC indicated Resident 233 was sent to the hospital for further evaluation and treatment. During a review of a late entry Progress Note dated 5/31/2025 at 6:35 p.m., the Progress Note indicated Resident 233 had an unwitnessed Resident-to-Resident altercation. The Progress Note indicated Resident 233 had swelling to the face (lip, forehead and check) and bleeding from the nose. The Progress Note indicated Resident 233 was transferred to GACH 3 via 911 at 6:45 p.m. per physician's order. During a review of Resident 233's IDT note dated 6/2/2025 at 8:31a.m., the IDT note indicated on 5/31/2025 at 6:35 p.m., there was an unwitnessed resident-to-resident altercation in Resident 23's room. The IDT note indicated LVN 7 discovered Resident 23 lying on the floor against a nightside and Resident 23 standing by the foot of the bed. The IDT note indicated Resident 233 was observed with swelling to the face (lip, forehead, and cheek), with scant (minimal) bleeding noted. The IDT note indicated LVN 7 applied a cold compress to Resident 233 and placed on 1:1 for monitoring and safety precautions. The COC indicated Resident 233 had a right cheek abrasion 5.0 centimeter (cm- unit of length) in length by 3.0 cm in width orbital discoloration. During a review of a Progress Note dated 5/31/2025 at 9:16 p.m. the Progress Note indicated Resident 233 was bleeding from his nose profusely but was able to stop the bleeding with first aid. During a review of Resident 233's GACH 3 record dated 6/4/2025, GACH 3 record indicated the Computed tomography (CT- medical imagining technique to obtain internal images of the body) of the head without contrast (substance taken by mouth or injection into the vein to help visualize the brain and surrounding area) indicated Resident 233 had a left frontal scalp (front area of head located behind the forehead) hematoma (bruise). During an interview on 6/11/2025 at 4:47 p.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 233 was always walking around. CNA 4 stated while he (CNA 4) was walking in the hallway (date unspecified), he observed Resident 233 go into another resident's room and redirected him to the patio. CNA 4 stated on 5/31/2025 when he was tending to a different resident in another room, he heard Resident 23 screaming for help and observed CNA 9 and LVN 7 run to Resident 23's room. CNA 4 stated when he got to Resident 23's room he observed Resident 233 on the floor sitting down in the middle of the door against the cabinet with a bloody nose that was dripping over his mouth, chin, and on one side of the cheek. During an interview on 6/11/2025 at 5:14 p.m., with LVN 7, LVN 7 stated he was in the Nursing Station (West side) charting when he suddenly heard Resident 23 yelling. LVN 7 stated the door to Resident 23's room was closed when he heard the yelling, and he opened the door. LVN 7 stated Resident 23 said get out of my room to Resident 233. LVN 7 stated Resident 23 was standing at the foot of the bed and Resident 233 was close to the bedside table sitting on the floor. LVN 7 stated Resident 233 had blood dripping from his nose. LVN 7 stated he called for assistance, and CNA 4 and CNA 9 arrived to assist, separated the residents, and attended to Resident 233 to stop the bleeding. LVN 7 stated CNA 7 arrived to assist, and indicated he called the Registered Nurse Supervisor 3 (RNS 3). LVN 7 stated while RNS 3 was interviewing the residents, Resident 23 said, What are you doing? What are you doing? LVN 7 stated he asked Resident 23 why he punched Resident 233 and Resident 23 replied Resident 233 was in his home, and he punched him. LVN 7 stated he brought the crash cart (a medical cart equipped with medical equipment and supplies used during emergencies) and grabbed a stack of gauze to stop Resident 233's bleeding from the nose. LVN 7 stated Resident 233 continued to bleed until the paramedics (emergency response team that provide medical care and transport people to hospitals) arrived. LVN 7 stated Resident 23 did not have 1:1 supervision that day (5/31/2025). LVN 7 stated staff need to walk around to check on the residents as anything can happen anytime, so staff have to monitor the residents. During an interview on 6/12/2025 at 9:32 a.m., with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated Resident 233 wanders. CNA 6 stated he has witnessed him go into other residents' rooms more than once. CNA 6 stated he has told an LVN (unknown) regarding Resident 233 going into other residents' rooms but does not recall who he told. During an interview on 6/12/2025 at 12:19 p.m., with CNA 9, CNA 9 stated Resident 233 is confused, wanders, and goes in and out of rooms. CNA 9 stated Resident 233 had 1:1 supervision before because he went into someone's room. CNA 9 stated Resident 23 is mostly to himself, would wave, but could not communicate with staff due to a language barrier. CNA 9 stated Resident 23 came from GACH 1 and had a history of being in jail for violence. CNA 9 stated when he (Resident 23) did not get his way (like wanting multiple packs or sugar but not giving him so much), he (Resident 23) would get aggressive. During an interview on 6/12/2025 at 12:44 p.m., with Resident 233's Family Member 2 (FM 2) FM2 stated she went to visit him (Resident 233) the day after the incident on 6/1/2025, she stated Resident 233 had a black eye, cut up face, and a busted lip. FM 2 stated she did not directly see Resident 233, but did see him through a video call. FM 2 stated she saw his eyes, face, and lips. FM 2 stated the staff did not provide them any information regarding how it happened. FM 2 stated Resident 233 had no recollection of the incident. FM 2 stated Resident 233 was not a fighter and would not say something to provoke you to get mad as that is not his character. FM 2 stated Resident 233 tends to wander when he's restless or when he does not want to be in that place. FM 2 stated if someone is showing him something or he is watching animals on screens, robots, dinosaurs, dominos, it would distract him for a long time. During a concurrent interview and record review on 6/12/2025 at 4:42 p.m., with the Regional Administrator (RADM), the RADM stated once Resident 233 returned to the facility from GACH 3, Resident 233 was placed on 1:1 for precaution because he wandered into residents' rooms. The RADM stated when he spoke to the staff, the staff indicated Resident 233 tended to roam the halls and to the smoking patio. The RADM stated he believed the incident between Resident 23 and Resident 233 was preventable as both residents were on monitoring every two hours. The RADM stated during the time of the incident, they did not have staff walking around the unit, but had designated people to monitor the residents every two hours and indicated the CNAs and LVNs were monitoring the residents in the facility at that time. During an interview on 6/13/2025 at 10:13 a.m., with the Administrator (ADM), the ADM stated residents have the right to wander safely and freely and indicated he does not know if a resident would be placed on 1:1 if a resident goes into another resident's room once, but they would address the behavior from the beginning and discuss it during the IDT meeting. The ADM stated regarding the abuse allegation of resident striking another resident; the statement received from Resident 23 was that Resident 233 was going through his belongings, and that may have been what upset Resident 23, and not so much that Resident 233 was in the room. The ADM stated going into another resident's room would be a behavior that would be care planned if it happened repeatedly but is not sure if it would be care planned if it was an incident that occurred for the first time. During an interview on 6/13/2025 at 3:46 p.m., with the Director of Nursing (DON), the DON stated the residents in the secured unit (unit where Resident's 23 and 233 were housed) are psychologically complex and require closer behavioral monitoring and management. The DON stated residents that have had multiple falls or having behaviors such as wandering or aggression need to be monitored closely, and they would require a 1:1 monitoring. The DON stated in this resident-to-resident altercation; Resident 233 was redirectable. The DON stated Resident 23 had a history of aggression and came from a prison. The DON stated anyone, even dementia residents have the potential for aggression. During a review of the facility's policy and procedure (P&P), titled, Resident Rights, dated January 2025, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse.

Based on interview, record review, the facility failed to ensure residents received their mail in a timely manner, including mail delivery on Saturdays for seven of eleven residents (Residents 75, 76, 115, 122, 166, 191, and 212) who attended the resident council meeting (scheduled gathering of residents in a long-term care facility, where they discuss issues related to their quality of life). This deficient practice had the potential for violating their right to communicate promptly with individuals within and outside the facility. Findings: During a resident council meeting on 6/10/2025 at 2:00 p.m., seven out of eleven residents who attended the meeting stated they did not get mail and packages on Saturdays, because the mail and packages were delivered to them only on Mondays through Fridays. During an interview on 6/10/2025 at 3:29 p.m., with the Activities Director (AD), the AD stated the activities department assisted the social services department in delivering the mail and packages to the residents. The AD stated the resident mail and packages were not delivered on Saturday, but only Monday through Friday. During an interview on 6/10/2025 at 3:37 p.m., with the Social Services Director (SSD), the SSD stated the social services department delivered the mail and packages to the residents. The SSD stated the residents' mail and packages were not delivered on Saturdays, but only Monday through Friday. The SSD stated residents' mail and packages were delivered on Saturdays only when he was at the facility on a Saturday. The SSD stated the last time he worked on a Saturday was in May, and he then delivered the mail and packages. During an interview on 6/10/2025 at 3:56 p.m., with the Receptionist, the Receptionist stated she sorted the mail and packages Monday through Friday, when she was at work. The Receptionist stated she would place any mail and packages received on Saturday, on a table near the front desk, to be sorted on the following Monday and placed in the SSD's mailbox, for delivery to the residents. During a concurrent interview and record review on 6/10/2025 at 4:48 p.m., with the SSD, the Social Services Department schedule for May and June 2025 were reviewed. The SSD stated the Social Services Department schedules for May and June did not show the SSD or any social services staff worked on Saturday. During an interview on 6/13/2025 at 11:17 p.m., with the Director of Nursing (DON), the DON stated the mail and packages are delivered to the residents on Monday through Friday because the SSD had to help the residents in opening their mail and packages because they wanted to make sure the residents are safe with their packages. The DON further stated a Manager of the Day or a department head can assist with the delivery of mail and packages on Saturday. During a review of the facility's P&P titled Mail Delivery Policy dated 1/2025, the P&P documented the purpose of this policy is to ensure that all residents in skilled nursing facilities receive their mail promptly and securely, while maintaining their privacy and dignity.

Based on interview and record review, the facility failed to: 1. Ensure there were adequate indications for the use of Abilify and Risperdal (antipsychotic medications used to treat mental illness) by failing to identify and document the use of non-pharmacological interventions (attempts to modify resident behavior without the use of medications) in two of five residents sampled for unnecessary medications (Resident 179 and 209.) 2. Ensure Abilify was necessary to treat a specific condition as diagnosed and documented in the medical record in one of five residents sampled for unnecessary medications (Resident 179.) 3. Monitor and document the target behavior of self-isolation in the Medication Administration Record (MAR - a record of all medication administration and monitoring done for a resident) related to the use of Celexa (an antidepressant medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 179.) 4) The facility failed to monitor the targeted behavior, and side effects related to Olanzapine (antipsychotic [medication used to treat mental illnesses that cause a break with reality]medication) and to ensure the monthly behavior summary report was completed related to Olanzapine use for May 2025 for Resident 168. 5) The facility failed to monitor the behavior manifestation for the use of clonazepam (antianxiety [used to treat a mental condition characterized by excessive fear about real or perceived threats, typically leading to avoidance behaviors and often to physical symptoms] medication) for Resident 68. 6) The facility failed to monitor the side effects for the use of divalproex sodium (antipsychotic medication) for Resident 22. These deficient practices of failing to identify and document non-pharmacological interventions, ensure antipsychotic medication was used to treat a resident's specific, diagnosed condition, and monitor target behaviors related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior)increased the risk that Residents 179 ,209,168,68 and 22 could have experienced adverse effects (unwanted or dangerous medication-related side effects) for five of five sampled Residents related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: 1. During a review of Resident 179's admission Record (a document containing a resident's diagnostic and demographic information), dated 6/12/25, indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including: dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life) and major depressive disorder (MDD - a mental illness characterized by depressed mood, difficulty sleeping, and lack of interest in usually enjoyable activities.) During a review of Resident 179's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 4/27/25, indicated he did not have the capacity to understand and make medical decisions. During a review of Resident 179's Physician Order Summary (a monthly summary of all active physician orders), dated 6/11/25, indicated, on 5/12/25, he was prescribed the following psychotropic medications: 1. Abilify 2 milligrams (mg - a unit of measure for mass) to take 1/2 tablet by mouth one time a day for major depressive disorder manifested by irritability/agitation leading to resistive to care. 2. Celexa 20 mg by mouth one time a day for major depressive disorder manifested by self-isolation. During a telephone interview on 6/11/25 at 2:41 PM with the psychiatric nurse practitioner (NP 1), NP 1 stated she did not initially prescribe Abilify for this resident but believes it was prescribed by another psychiatric nurse practitioner (NP 2) for adjunct treatment of depression (a small dose of antipsychotic medication used along with an antidepressant medication in order to increase symptom resolution of depression) along with Celexa. NP 1 stated she has been gradually decreasing the dose of Abilify with a goal to eventually discontinue it. During a review of Resident 179's Psychiatric Follow-Up Note (a clinical progress note summarizing care provided by a psychiatric provider), dated 12/17/24, indicated the Nurse Practitioner (NP 2) initially prescribed Rexulti (an antipsychotic medication used to treat mental illness) for behaviors of wandering around the unit, verbal outbursts and banging at times. Further review of NP 2's psychiatric progress note indicated Rexulti was not covered by Resident 179's insurance and was subsequently switched to Abilify, Further review of the psychiatric progress note indicated NP 2 made no mention of Abilify being used as adjunct therapy for Resident 179's depression or for which of Resident 179's diagnoses it was prescribed. During a telephone interview on 6/12/25 at 10:43 AM with NP 2, NP 2 stated she initially prescribed Rexulti for behaviors related to dementia and switched to Abilify because Rexulti was non-formulary (not covered by insurance). NP 2 stated she was advised by facility staff she could not use Abilify for dementia and then asked the facility to discontinue the medication. NP 2 stated, to her knowledge, it has since been managed by another provider (NP 1). NP 2 stated she did not prescribe the Abilify as adjunct therapy for depression. NP 2 stated that it does not make any clinical sense to use Abilify as adjunct therapy for Resident 179's depression as the dose of the Celexa has not been optimized and the target behaviors listed for the Abilify are completely different than those from the Celexa. NP 2 stated using antipsychotic medications without a clear indication for use increases the risk that Resident 179 may have adverse effects related to antipsychotic use which could lead to a decrease in quality of life. During a review of Resident 179's available Interdisciplinary Care Team (IDT - a team of professionals from various backgrounds who meet quarterly with care providers and family to provide an outline and plan for a resident's care) conference notes, dated between 10/29/24 to 5/9/25, indicated the conference participants did not identify or document any resident-specific, non-pharmacological interventions to utilize as an approach to address Resident 179's behavior of irritability/agitation leading to resistive to care. During a review of Resident 179's available care plans, last reviewed 5/30/25, indicated the facility did not identify any resident-specific, non-pharmacological approaches as targeted interventions to address Resident 179's behavior of irritability/agitation leading to resistive to care. During a review of Resident 179's MAR for June 2025 indicated the facility was not monitoring or documenting any non-pharmacological interventions related to Resident 179's behavior of irritability/agitation leading to resistive to care related to his use of Abilify and was not monitoring or documenting behaviors of self-isolation related to his use of Celexa. 2. During a review of Resident 209's admission Record, dated 6/12/25, indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including: dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life.) During a review of Resident 209's H&P, dated 5/28/25, indicated it was unclear whether Resident 209 had the capacity to make medical decisions. During a review of Resident 209's Physician Order Summary, dated 6/11/25, indicated, on 5/27/25, he was prescribed the following psychotropic medication: 1. Risperdal 0.5 mg to take 1 tablet by mouth two times a day for schizophrenia manifested by agitation leading to non-compliant with ADLs (activities of daily living such as bathing and brushing teeth) care and medication. During a review of Resident 209's IDT conference notes, dated between 4/17/25 and 6/2/25, indicated the conference participants did not identify or document any resident-specific, non-pharmacological interventions to utilize as an approach to address Resident 209's behavior of agitation leading to non-compliant with ADLs care and medication. During a review of Resident 209's available care plans, last reviewed 5/1/25, indicated the facility did not identify any resident-specific, non-pharmacological approaches as targeted interventions to address Resident 209's behavior of agitation leading to non-compliant with ADLs care and medication. During a review of Resident 209's MAR for June 2025 indicated the facility was not monitoring or documenting any non-pharmacological interventions related to Resident 209's behavior of agitation leading to non-compliant with ADLs care and medication related to his use of Risperdal. During an interview on 6/12/25 at 11:45 AM with the Director of Nursing (DON), the DON stated the facility failed to identify and document the use of resident-specific, non-pharmacological interventions to address Resident 179 or 209's problematic behaviors. The DON stated the facility does have certain non-pharmacological interventions that are used to deal with problematic behaviors in general, but there is no documentation available in the residents' MARs or any other record indicating whether these interventions have been successful or not at mitigating their problematic behaviors. The DON stated the failure to identify and document non-pharmacological approaches to resident behaviors related to dementia increases the risk that they may receive antipsychotic therapy for longer or at higher doses than necessary, possibly causing adverse effects leading to a diminished quality of life. The DON stated the facility also failed to monitor Resident 179 for behaviors of self-isolation related to the use of Celexa in the MAR. The DON stated monitoring for these behaviors allows an objective assessment of whether the benefits outweigh the risks of the continued use of psychotropic medications. The DON stated without monitoring for these behaviors, there is a risk that residents receive psychotropic medications longer than necessary or at higher doses than necessary possibly causing an increased risk of adverse effects leading to medical complications or a diminished quality of life. During a review of the facility policy Antipsychotic Medication Use, revised January 2025, indicated Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . Diagnoses alone do not warrant the use of antipsychotic medication . antipsychotic medication will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; AND; 1. the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations, delusions, paranoia or grandiosity); or 2. behavioral interventions have been attempted and included in the plan of care . Antipsychotic medication will not be used if the only symptoms are one of more of the following: .wandering . restlessness . impaired memory . uncooperativeness . The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications . During a review of the facility's policy Dementia - Clinical Protocol, revised January 2025, indicated The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. Resident needs will be communicated to direct care staff through care plan conferences, during shift communication and through written documentation . The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements . During a review of the facility's policy Psychotropic Medication Use, revised February 2025, indicated Residents receiving psychotropic medication are monitored and the response to treatment is documented . Psychotropic medications are never used to sedate or alter a resident's behavior for discipline or for the convenience of staff . Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medication, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction . Adequate indications for use refers to the identified, documented clinical rationale for administering medication that is based on: an assessment of the resident's condition and therapeutic goals, a determination that non-pharmacological interventions are clinically contraindicated: and manufacturer's recommendations, clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that support the use of medication . The clinical rationale for use of psychotropic medication . is documented in the medical record. Documentation must include that behavioral (non-pharmacological) interventions were attempted but not successful, and these interventions were deemed clinically contraindicated . 4. During a review of Resident 168's admission Record, the admission Record indicated Resident 168 was admitted on [DATE], and readmitted to the facility on [DATE] with the diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) During a review of Resident 168's Minimum Data Set ([MDS] a resident assessment tool) dated 3/22/2025, the MDS indicated Resident 168's cognition (ability to make decisions of daily living) was severely impaired. During a review of Resident 168's Physician Order dated 3/17/2025, the Physician's Order indicated to administer olanzapine 5 mg via G-tube (gastrostomy tube, a small tube inserted through the abdomen and into the stomach to provide alternative way to deliver nutrition, fluids and medicine) at bedtime for schizophrenia manifested by disorganized thinking. This physician's order was discontinued on 6/4/2025. During a review of Resident 168's Order Summary Report dated 6/4/2025, the Physician's Order indicated to administer olanzapine 5 mg via PEG-tube (percutaneous endoscopic gastrostomy tube, a soft, plastic tube that's inserted through the skin and into the stomach to deliver nutrition, fluids and medicine) at bedtime for schizophrenia manifested by disorganized thinking. During a review of Resident 168's Medication Administration Record (MAR) dated 5/2025 and 6/2025, the MAR indicated Resident 168 was administered with olanzapine 5 mg from 5/1 to 6/2/25, and from 6/5 to 6/11/25. The MAR also indicated the side effects and behavior monitoring were documented on 5/1 to 6/3/25. During a review of Resident 168's Psychotropic Summary Sheet for olanzapine, the Psychotropic Summary Sheet indicated the monthly behavior and side effect monitoring for 5/2025 was not completed. During an interview on 6/11/2025 at 9:59 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was not monitoring Resident 168 for any behaviors and side effects related to the use of olanzapine. During an interview on 6/11/2025 at 11:36 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 168 should be monitored for adverse reactions and the targeted behavior for olanzapine. RN 1 confirmed there was no monitoring for adverse reactions and the target behavior for olanzapine from 6/5/2025. RN 1 confirmed the monthly behavior summary for 5/2025 was not completed. During an interview on 6/13/2025 at 10:24 p.m., with the Director of Nursing (DON), the DON stated when administering olanzapine, the nurses should monitor the resident for side effects and to intervene if there are side effects related to the use of olanzapine. The DON stated the target behavior for olanzapine use should also be monitored to determine if the medication is working as intended. The DON stated the resident's behavior manifestation and side effects for olanzapine should be monitored by the nursing staff, and should be documented in the MAR. The DON stated the monthly behavior summary for olanzapine use for May 2025 should have been completed from 6/1 to 6/5/25, to determine if the number of the target behavior increased or decreased. 5. During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was admitted to the facility on [DATE], and readmitted on [DATE] with the diagnosis of anxiety. During a review of Resident 68's MDS dated [DATE], the MDS indicated Resident 68's cognition was mildly impaired. During a review of Resident 68's Order Summary Report dated 6/9/2025, the Physician's Order indicated to administer clonazepam 0.5 mg one tablet by mouth for anxiety. Hold if sedated. During a review of Resident 68's MAR dated 6/2025, the MAR indicated Resident 68 was administered with clonazepam 0.5 mg from 6/10 to 6/12/2025. During an interview on 6/12/2025 at 8:44 a.m., with Licensed Vocation Nurse (LVN) 1, LVN 1 stated she was not monitoring Resident 68 for any behavior manifestation related to the use of olanzapine. During an interview on 6/12/2025 at 8:54 a.m., with Registered Nurse (RN) 1, RN 1 stated the physician's order for clonazepam should include a behavior manifestation and Resident 168 should be monitored for the targeted behavior. RN 1 confirmed Resident 68 was not being monitored for any behavior manifestation for the use of clonazepam. During an interview on 6/13/2025 at 11:05 p.m. with the DON, the DON stated the physician's order for clonazepam should include the resident's behavior manifestation, and the resident on clonazepam should be monitored for behavior manifestation for the use of clonazepam every shift. The DON stated Resident 68's behavior was not monitored related to the use of clonazepam. 6. During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE], and readmitted on [DATE] with the diagnosis of schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder). During a review of Resident 22's MDS dated [DATE], the MDS indicated Resident 22's cognition was severely impaired. During a review of Resident 22's Order Summary Report dated 5/12/2025, the Physician's Order indicated to administer divalproex sodium 125 mg two capsules by mouth every 12 hours for schizoaffective disorder manifested by mood swings as evidenced by crawling on the floor. During a review of Resident 22's MAR dated 5/2025 and 6/2025, the MAR indicated Resident 22 was administered with divalproex sodium from 5/12 to 6/12/2025. During an interview on 6/12/2025 at 1:53 p.m., with Licensed Vocation Nurse (LVN) 3, LVN 3 stated she was not monitoring Resident 22 for any side effects related to the use of divalproex sodium. During an interview on 6/12/2025 at 2:16 p.m., with Registered Nurse (RN) 2, RN 2 confirmed Resident 22 was not being monitored for any side effects for divalproex sodium. During an interview on 6/13/25 at 10:46 a.m. with the Director of Nursing (DON), the DON stated Resident 22 should be monitored for the side effects of the divalproex sodium every shift, and this should be document in the MAR. During a review of the facility's P/P titled Psychotropic Medication use dated 2/2025, the P/P indicated residents receiving psychotropic medication are monitored and the response to treatment is documented. The P&P also indicated the residents are monitored for adverse consequences associated with psychotropic medications .

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1.Nutritional supplement labeled store frozen with manufactures instructions to use within 14 day of thawing were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. Three boxes each with 50 single serve cartons of strawberry flavored nutrition supplements, two boxes of vanilla flavored nutrition supplements, 10 boxes of chocolate flavored nutrition supplements and one box containing 17 single serve cartons of chocolate and strawberry flavor supplements were stored in the reach in refrigerator with no thaw date. This deficient practice had the potential to result in food borne illness in 33 residents who are on nutrition supplements at the facility. 2.One large tray of previously prepared dessert containing fruits and cream and two plates of previously prepared salad (lettuce, tomato and chopped ham) were stored in the reach in refrigerator with no label and date. One opened nondairy creamer was stored in the reach in refrigerator with no open date and two medium size containers of dry cereal one with date 5/30/25-6/2/25 and another with dates 5/29/25 expired were stored in the dry storage area. 3.The coffee machine glass gauge pipe was stained with dark brown color residue. 4. When a cup of yogurt was left over night at Resident 39 bed side table. These deficiencies had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 218 of 223 residents who received food from the facility. Findings: 1. During an observation in the kitchen on 6/9/2025 at 9:00AM there were boxes of single serve cartons of nutrition supplements stored in the reach- in refrigerator with no date. Three boxes containing 50 cartons of strawberry flavored supplements, two boxes containing vanilla flavored supplements, 10 boxes containing chocolate flavored supplements and one box containing 17 single serve cartons of mixed flavor supplements stored in the reach in with no thaw date. During a concurrent interview 6/19/2025 at 9:15 a.m. with dietary supervisor (DS), DS stated the single serve carton of nutritional supplements are frozen and are stored in the refrigerator to thaw. DS stated the boxes have the delivery date and the supplements are stored in their original box. DS said once thawed they should be used within 14 days. DS agreed there were no thaw date on the boxes of the supplements. DS stated the one box with only 17 cartons containing mixed flavors is because staff cleaned the refrigerator and combined the remaining nutrition supplements from each almost empty boxes together. DS stated the supplements were delivered at different dates and should not be mixed. DS agreed there should be a date on the supplements to monitor date of thaw and to discard them if expired. DS was not sure when the single serve cartons of mixed flavors were thawed. DS stated shakes that are expired can make the residents sick. DS discarded the shakes that were combined from different boxes. During a review of the facility's policy titled Procedure for refrigerated storage (dated 2023) indicated, Supplemental shakes which are taken from the frozen stated and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator. During a review of the 2022 U.S. Food and Drug Administration Food Code titled, Ready to Eat, Time/Temperature control for safety food, Date marking Code#3-501.17, indicated, Ready to eat, time temperature control for safety food prepared and packaged by food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed, sold, or discarded. 2.During an observation in the reach- in- refrigerator on 6/9/2025 at 8:45AM, there was one large tray of pear mixed with cream stored in the refrigerator with no label and date. During the same observation there were two plates of salad including lettuce tomato and sliced ham covered with plastic wrap and stored with no date and one open container of non-dairy creamer with a receive date of 5/2/2025. During a concurrent observation and interview with Dietary supervisor (DS) on 6/9/2025 at 8:45AM, DS stated ready to eat food is kept for 3-5 days in the refrigerator. DS stated all items should have a use by date to discard before they are expired. DS stated expired food can make residents sick. During the same observation and record review of the menu with the DS on 6/9/2025 at 8:45AM, DS stated the dessert with pear and cream was from last weeks dinner and should have been discarded. DS stated the plates of salad are made daily for residents who request large salad with meals, and it should have a date on it. During a concurrent interview with DS and review of the facility storage guideline posted on the wall, DS stated salad greens are good for 3-5 days in the refrigerator and non-dairy creamer is good for 3 weeks. DS didn't know when the salad was prepared and when the non-dairy creamer was opened. During an observation in the dry storage area on 6/9/2025 at 10:00AM, there was one medium size plastic container with dry cereal (granola topping), covered with a plastic wrap and with date 5/30/25-6/2/25 expired, and another medium size plastic container with coconut dry cereal (granola topping) with dates 5/29/25. During a concurrent observation and interview with DS, DS stated the containers should be tightly covered with a lid and not with plastic wrap. DS could not verify if the dates were accurate and stated will discard the cereal because they are expired. During a review of facility's policy titled, Labeling and Dating of Foods (dated 2023) the policy indicated, Newly opened food items will need to be closed and labeled with an open date and used b the date that follow the storage guidelines .All prepared foods need to be covered, labeled and dated, leftovers will be covered, labeled and dated. During a review of facility's policy titled, Storage of Food and Supplies (dated 2023) the policy indicated, Dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc.) should be stored in seamless metal or plastic containers with tight covers .Dry storage items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc. will be tightly closed, labeled and dated. During a review of facility's Dry goods storage guideless (dated 2023), the guidelines indicted for cereal, ready to eat once opened on shelf store for 2 months, keep them dry and tightly covered. 3.During an observation in the kitchen on 6/9/2025 at 9:45AM, observed the coffee maker machine had glass gauge pipe in front of the machine. There was visible coffee in it and there were dark brown stains inside the pipe. During a concurrent interview with Dietary Aide (DA1), DA1 stated the coffee machine is cleaned at the end of day but the glass pipe on the outside is not cleaned by staff. DA1 stated they do not have the equipment to clean the glass pipe. During the same observation and interview with DS on 6/9/25 at 9:45AM, DS stated the coffee machine is cleaned by an outside company once a month. DS stated the coffee machine glass gauge pipe looks dirty and will contact the outside vendor. DS stated outside coffee machine vendor uses a long thin brush to clean the pipe. facility does not have the long thin brush to clean the pipe. DS stated the stained and dirty coffee maker can contaminate the coffee and change the quality of the coffee. During a review of the facility's cleaning schedule and check list not dated, the coffee machine cleaning was not included in the cleaning schedule. During a review of the facility's policy titled, Coffee Brewing Equipment (dated 2023) the policy indicated, coffee urns and coffee service equipment must be free of stains and foreign film build-up. 4.During an initial tour and observation on June 9, 2025, at 9:19 a.m. in Resident 39's room, a cup of yogurt was at Resident 39's bedside table. During an interview, on June 9, 2025, at 9:32 a.m., with Certified Nurse Assistant (CNA) 5, in Resident 39's room, CNA 5 stated the cup of yogurt on Resident 39's bedside table was from the day before. CNA 5 stated she did not see it when she was assisting Resident 39 eat her breakfast. CNA 5 stated staff from night shift should check the snacks if a resident ate it or not and should throw it away if left for a long time. During an interview, on June 11, 2025, at 9:06 a.m., with the Director of Staff Development (DSD), the DSD stated staff that pass out the snacks should come back around to check if the residents have consumed the snack item and discard it accordingly. The DSD confirmed a snack like yogurt should not have been left at the bed side overnight in room temperature for it may cause stomach upset to a resident if consumed. A review of facility's policy and procedure (P&P) titled Snacks dated January 2025, indicated .All snacks shall be safely prepared, stored, and distributed in a sanitary and respectful manner .6. Store snacks in compliance with food safety standards .8. Refrigerated snacks must be kept at 41 F .15. Nursing staff/CNAs are responsible for distribution, assistance, and documentation . A review of facility's P&P titled Food-Borne Illnesses dated January 2025, indicated All food must be prepared, stored, and served per safe food handling guidelines (e.g. temperature, hygiene) .

Based on interview and record review, the facility failed to ensure two of nine sampled residents (Resident 1 and Resident 2), who were assessed at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), received supervision to prevent elopement from the facility. These deficient practices resulted in Resident 1 and Resident 2 eloping from the facility on 5/18/2025 at approximately 12 p.m. without staff awareness. Resident 1 and Resident 2 were located by Resident 1's Family Member (FM) 1 approximately 20 miles from the facility on 5/19/2025 at approximately 3 p.m. (approximately 27 hours after they were believed to have eloped from the facility). Both residents were transported to a General Acute Care Hospital (GACH) for evaluation and treatment, where they remained for four days. Resident 1 was admitted to the GACH with altered mental status (a change from a person's normal mental state) and Resident 2 was assessed and treated for a urinary tract infection ([UTI] an infection in the bladder/urinary tract). These deficient practices placed Resident 1 and Resident 2 at risk of exposure to inclement weather (unpleasant or severe weather conditions that can disrupt activities, create hazardous situations, or pose risks to safety), vehicular accident and injury, harm by other individuals and death, and placed 144 residents, who resided in the facility, and who were assessed as high risk for wandering/elopement, at risk for elopement from the facility. On 5/20/2025 at 7:03 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to identify Resident 1 and Resident 2 prior to allowing them entry into the facility's lobby from a locked unit and permitting them to elope the building through the facility's front door. On 5/23/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 5/23/2025 at 3:06 p.m., in the presence of the facility's DON and ADM. The facility's IJRP included the following immediate actions: On 5/19/2025 - 5/20/2025 a review 228 residents' medical records was conducted by the DON and IDT members to ensure each resident had an updated Elopement/Wandering Risk assessment and care plan. 144 residents were identified at risk for elopement/wandering. 10 of the 144 at risk residents were identified with no elopement risk/wandering care plans, their care plans were updated to reflect interventions to ensure residents were free from elopement episodes and free from any injuries if wandering. An Elopement binder located at the receptionist desk and in Point Care Click ([PCC] a healthcare management platform designed to simplify resident care and improve efficiency in senior care facilities) Special Instructions (a mechanism in PCC to identify if a resident is at risk for elopement/wandering) were updated on 5/20/2025 to reflect residents' appropriate risk for elopement/wandering. On 5/18/2025, the Infection Preventionist Nurse (IPN) Nurse Manager and Regional Director of Clinical Services (RDCS) initiated an in-service for the licensed nursing staff regarding the facility's policy and procedure on elopements, and emergency procedure when a resident is missing/has eloped. On 5/19/2025 an In-service was initiated by the DSD for facility staff regarding residents at risk for elopement, identifying wandering and exit seeking behaviors, interventions for wandering and exit seeking behaviors, new visitor screening process for visitors/outside providers, new staff entrance/exit process, staff/visitor/outside providers' badges are visible and any individuals without proper badge/identification will not be permitted entry or exit through the locked doors, when opening locked doors ensure residents are not following them, vigilance in noticing surroundings when entering or leaving locked doors. Staff are no longer permitted to enter or exit through the front doors to lessen crowding and increase visibility. Staff will begin utilizing the metal doors located East of the front entrance at the front of the facility. A sign has been placed on the front door directing staff to the new entrance location. All staff will enter the facility through an alternative entrance on the day and evening shifts, and after hours, staff entering the building will press a button and staff inside the building, after viewing a camera, will let them in. Two receptionists are currently assigned to screen visitors from 7 a.m. - 7 p.m., at the front lobby daily Monday through Sunday. During lunch breaks, the two receptionist will relieve each other, there will be only one receptionist during lunch breaks. On 5/20/2025 the facility upgraded entrance doors with a magnetic security/closure function in addition to a keypad entry that was installed. On 5/19/2025 the Receptionist and CNA involved were placed on leave pending the outcome of the investigation. The Receptionist and CNA's termination will be processed effective 5/23/2025. The DSD/designee will conduct hallway rounds three times per week to ensure residents are supervised and redirected to appropriate units. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a type of schizophrenia [a mental illness that affects a person's thoughts, feelings and behaviors] marked primarily by distrust of others, and false beliefs of being persecuted, harmed, or spied upon) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/1/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (problems with a person's ability to think, learn, remember, use judgement, and make decisions) for daily decision making and required supervision (helper provides verbal cues and/or touching /steadying to complete the activity) to complete activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Wandering Risk Observation/assessment dated [DATE], the Wandering Risk Observation/Assessment indicated a score of nine indicating Resident 1 was at risk for wandering. During a review of Resident 1's untitled Care Plan dated 4/23/2025, the Care Plan indicated Resident 1 was an elopement risk/wanderer related to her attempts to leave the facility unattended. Under this Care Plan, the goal was that Resident 1 would not leave the facility unattended through the review date of 6/23/2025. The Care Plan's interventions included distracting Resident 1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books, monitoring Resident 1's location every two hours and document wandering behavior and attempted diversional interventions in the behavior log. During a review of Resident 1's Change of Condition (COC) form dated 5/18/2025, the COC indicated on 5/18/2025 at approximately 5:41 p.m., Resident 1 could not be located anywhere in the facility and Code Black was initiated. The COC indicated at 5:41 p.m., the DON, ADM, local police and Resident 1's Responsible Party (RP) were notified of Resident 1's disappearance. During a review of Resident 1's Nursing Progress Note dated 5/19/2025 and timed at 2:56 p.m., Family Member (FM) 1 reported he located Resident 1 near his residence. The Nursing Progress Note indicated Resident 1 was transported to a GACH by the facility's ADM and SSW for assessment and clearance. During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the GACH on 5/19/2025. During a review of the GACH's Emergency Department (ED) Progress Note dated 5/19/2025, the ED Progress Note indicated Resident 1 was admitted with a diagnosis of altered mental status. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of dementia. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had impaired cognitive skills for daily decision making and required partial/moderate assistance (helpers does less than half the effort) to complete ADLs. During a review of Resident 2's Wandering Risk Observation/assessment dated [DATE] the Wandering Risk Observation/Assessment indicated a score of eleven indicating Resident 2 was a high risk for wandering. During a review of Resident 2's untitled Care Plan dated 9/5/2024, the Care Plan indicated Resident 2 was an elopement risk/wanderer related to disorientation to place and impaired safety awareness. The care plan indicated Resident 2 wandered aimlessly and significantly intruded on the privacy or activities of others. Under this Care Plan, the goal was that Resident 2 would not leave the facility unattended through the review date of 12/04/2024. The Care Plan's interventions included monitoring Resident 2's location, documenting wandering behavior and attempted diversional interventions in the behavior log. During a review of Resident 2's COC dated 5/18/2025, the COC indicated on 5/18/2025 at approximately 5:41 p.m., Resident 1 could not be located anywhere in the facility and Code Black was initiated. The COC indicated at 5:41 p.m., the DON, ADM, local police and Resident 2's RP were notified of Resident 2's disappearance. During a review of Resident 2's Nursing Progress Note dated 5/19/2025 and timed at 2:56 p.m., the Nursing Progress Note indicated FM 1 reported he located Resident 2 near his residence. The Nursing Progress Note indicated Resident 2 was transported to a GACH by the facility's ADM and SSW worker for assessment and clearance. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the GACH on 5/19/2025. During a review of the GACH's ED Progress Note dated 5/19/2025, the ED Progress Note indicated Resident 2 was admitted to the GACH with a diagnosis of urinary tract infection, and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar [b/s] control and poor wound healing). During an interview on 5/20/2025 at 10:56 a.m., and a subsequent interview at 12:42 p.m., RCP 1 stated on 5/18/2025 at approximately 12:10 p.m. to 12:15 p.m., CNA 1 rang the doorbell from inside the facility's locked area alerting her (RCP 1) to unlock the door, which led to the facility's lobby area, so that the visitors (Resident 1 and Resident 2) could be allowed out. RCP 1 stated she unlocked the door, and Resident 1 and Resident 2 entered the lobby and continued out the facility's front entrance. RCP 1 stated Resident 1 and Resident 2 did not have on green visitors stickers, but she stated that was not uncommon because visitors entered the facility through a different entrance when she was on her lunch break. RCP 1 stated she found out later that evening, those visitors were residents. RCP 1 stated she was not familiar with the residents in the facility, and she did not recognize the visitors were actually residents. RCP 1 stated there was no process to check out visitors when they left the facility, she just told Resident 1 and Resident 2 goodbye and have a nice day when they left out of the building through the facility's front door. During an interview on 5/20/2025 at 11:48 a.m., CNA 1 stated on 5/18/2025 at approximately lunchtime she was passing by the locked doors that led to the facility's lobby area and saw two ladies that did not look like residents near the doors. CNA 1 stated she pressed the button (doorbell) to signal for RCP 1 to unlock the doors, which she (RCP 1) did, and the two ladies proceeded into the lobby area. CNA 1 stated she saw one of the two ladies wearing a green visitor sticker which was given to visitors when they enter the facility. During an interview on 5/20/2025 at 2:42 p.m., CNA 4 stated on 5/18/2025 at approximately lunchtime, she did not see Resident 1 or Resident 2 when she delivered lunch trays to their shared room. CNA 4 stated she does rounds on her assigned residents every two hours, during her rounds on 5/18/2025, she did not see Resident 1 and Resident 2 after delivering their lunch trays and did not look for them because she assumed they were on the facility's patio. CNA 4 stated she did notice their lunch trays were still in the resident's room and were untouched. CNA 4 stated she found out later that night, Resident 1 and Resident 2 were missing from the facility. During an interview on 5/20/2025 at 2:15 p.m., CNA 5 stated when she started her shift at 3 p.m., on 5/18/2025 she noticed Resident 1 and Resident 2's lunch trays were still in their room untouched. CNA 5 stated she asked staff members if they had seen the residents, but nobody had seen them. CNA 5 stated prior to dinner time (unsure of the exact time), she asked other staff to help her look for Resident 1 and Resident 2 and they (her and the other staff) continued looking for them through dinner time. CNA 5 stated she found out the residents had eloped when she heard Code Black (an alert to facility staff to initiate a search of the building and premises for a resident who left the facility without authorization), being activated. During an interview on 5/20/2025 at 3:04 p.m., the DON stated Resident 1 and Resident 2's whereabouts in the facility should have been monitored every two hours because they were high risk for wandering/elopement. The DON stated staff should have confirmed if the two ladies (Resident 1 and Resident 2) were actual visitors prior to allowing them into the facility's lobby area and then allowing them to exit through the facility's front door. The DON stated the facility had no check out process for visitors and none was utilized by RCP 1 prior to Resident 1 and Resident 2 eloping from the facility. The DON stated the residents' elopement placed them at risk for harm by car accident and/or injury by other individuals, missed medications, no access to food or water, and exposure to different weather conditions. During a review of the facility's undated Policy and Procedure (P/P) titled Wandering Residents and Elopements the P/P indicated the facility maintains a process to assess residents for elopement risk, or who are at risk of unsafe wandering and will implement risk reduction strategies. The P/P indicated interventions that may be used for residents identified as high risk for elopement include but may not be limited to the physical plant is secured to minimize the risk of elopement through safety locks or keypad entry that restrict access to dangerous areas.

Based on interview and record review, the facility failed to ensure a resident, who was diagnosed with atrial fibrillation ([Afib] abnormally fast heartbeat that may lead to blood clots) and received Warfarin (a medication used to prevent blood clots from forming) was free from significant medication errors for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1's Warfarin was administered as ordered by Resident 1's physician's Nurse Practitioner (NP). 2. Ensure licensed nurses did not administer multiple orders of duplicate therapy of Warfarin to Resident 1 on 11/21/2024, 11/22/2024, 11/23/2024, 11/25/2024 11/29/2024, 11/30/2024, 12/1/2024, 12/2/2024, 12/9/2024 and 12/10/2024 that included a dose of Warfarin that should have been discontinued on 11/19/2024. 3. Ensure licensed nurses monitored medication administration times and critical (values that are significantly outside the normal range) laboratory values to prevent and detect medication errors. These failures resulted in Resident 1's transfer to a General Acute Hospital (GACH) on 12/27/2024 where he was diagnosed with a subdural hematoma ([SDH] a collection of blood on the surface of the brain) measuring 12 millimeters ([mm] a metric unit of measurement, used for medication dosage and/or amount). Resident 1 upon admission to the GACH was intubated (insertion of a tube either through the mouth or nose and into the airway to aid in breathing) and administered Andexxa (a medication given to patients who are on anticoagulant medication [a class of drugs that help prevent blood clots and dissolve existing ones] to treat life-threatening or uncontrolled bleeding. On 1/4/2025 at 5:59 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to administer and monitor Resident 1's Warfarin medication according to the prescriber's order. On 1/5/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After an onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 1/5/2025 at 6:45 p.m., in the presence of the facility's DON and ADM. The facility's IJRP included the following immediate actions: a. On 1/4/2025, a comprehensive three-way audit of 13 medication carts was initiated with an expected completion date of 1/5/2025. This audit was conducted collaboratively by the Pharmacy and facility staff to ensure the following objectives were met; medications were administered correctly based on supply availability, medications availability, match of the medication blister pack/medication container to the physician orders, proper documentation, and medications that were revised previous orders were discontinued. Any issues identified were immediately corrected by the auditing nurse and communicated to the DON for review. b. On 1/5/2025, one on one education was provided to the Consulting Pharmacist ([CP] a licensed pharmacist who provides expert advice on the safe use and administration of medication), by the Pharmacy Regional Director of Operations (PRD). The session focused on the CP's role in conducting monthly drug regimen reviews for residents receiving anticoagulant medications. The key topics included the importance of monitoring medication administration times, critical lab values, and the pharmacist's collaborative role as part of the Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals. c. On 1/5/2025, the Pharmacy Consultant conducted a Drug Regimen Review for 23 current residents who were receiving anticoagulant medication. Recommendations were communicated to the resident's physicians by the facility nursing staff and addressed accordingly. d. On 1/4/2025, a facility wide audit was conducted by the facility nursing staff for all residents utilizing the Anticoagulant Audit tool to ensure current residents receiving anticoagulant medication had orders to monitor for signs and symptoms (s/s) of bleeding every shift such as but not limited to: bleeding, discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy (a state of being drowsy and dull, listless, and unenergetic, indifferent and lazy, sluggish and inactive), bruising, sudden changes in mental status and/or vital signs (v/s), shortness of breath (SOB), or nose bleeds. The audit identified all current residents receiving anticoagulant therapy had routine monitoring of anticoagulant side effects. e. On 1/4/2025, a facility wide audit was conducted by the nursing staff to ensure proper administration of anticoagulant medications utilizing the Anticoagulant Audit tool The audit confirmed that all current residents who were prescribed anticoagulant medications were accurately identified, and no other residents were receiving those medications inappropriately. f. On 1/4/2025, the Assistant Regional Director of Clinical Services conducted a thorough chart review for 23 residents currently receiving anticoagulant medications. The review was undertaken to ensure the accuracy of medication orders, accurate monitoring of side effects with recommended frequency and to verify there were no instances of incorrect duplicate medications. g. On 1/4/2025 an in-service was initiated to licensed nurses by the DON focusing on the Anticoagulation Therapy Clinical Protocol including Warfarin's dosage, side-effects, significance of laboratory tests, and International Normalized Ratio ([INR] a blood test that measures how long it takes for blood to clot) therapeutic levels (level of medication in the blood to achieve its desired effect). h. On 1/4/2025, the DON initiated an in-service for licensed nurses to address key medication management objectives. The training aimed to ensure the following: medications were administered correctly based on the available supply, availability of medication was verified, the medication blister packs or containers matched physician orders, proper documentation was maintained, and any medication changes were accompanied by the discontinuation of previous orders. The expected completion date for the in-service is January 5, 2025. Nurses who were unable to attend the session were instructed to report to the DON/designee during their next scheduled shift to receive the in-service. 1. On 1/4/2025, the DON initiated an in-service for licensed nurses focused on ensuring the accuracy of medication orders, proper monitoring of side effects at the recommended frequency, and verifying the absence of incorrect or duplicate medications. The in-service is expected to be completed by 1/5/2025. Nurses unable to attend the in-service were instructed to report to the DON/designee during their next scheduled shift to receive the in-service. j. On 1/4/2025, an in-service was provided initiated to licensed nurses by DON regarding policy and procedure on Medication Administration to ensure medications are administered per physician's order, orders are clarified if not available/not matching with supply at hand, and medications that were changed and have ongoing previous orders are clarified and discontinued. k. The Medical Director (MD) was notified of the IJ on 1/4/2025 at 6:45pm by the ADM. l. An Ad Hoc (when necessary or needed) Quality Assessment and Assurance ([QA&A] a group that ensures the quality of care and life in a facility by identifying and fixing quality issues) Committee meeting was scheduled for 1/5/2025, to discuss the IJRP. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Afib. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/10/2024, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) on facility staff to complete his activities of daily of living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's undated Care Plan, the Care Plan indicated Resident 1 was at risk for bleeding and bruising secondary to anticoagulant therapy related to the use of Warfarin. The Care Plan indicated labs should be completed as ordered and abnormal results should be reported to the physician. During a review of Resident 1's Physician's Order dated 11/5/2024, the Physician's order indicated Resident 1's Prothrombin ([PT] a factor in the blood that helps it clot properly)/INR was to be drawn on 11/7/2024 one time only. During a review of Resident 1's Physician's Order Summary Report dated 11/7/2024, the Physician's Order Summary Report indicated to administer Warfarin 4.5 milligrams ([mg] unit of measurement) one time a day (9 a.m.) for Afib. During a review of Resident 1's Physician Order dated 11/7/2024, the Physician order indicated to draw Resident 1's INR on 11/10/2024. During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 4.27 (INR range 2.0-3.0) and was flagged as critical. During a review of Resident 1's Change in Condition (COC) Note dated 11/13/2024, the COC note indicated Resident 1's INR was reported as 4.27 to Resident 1's physician, who ordered Vitamin K (a vitamin that plays a role in helping blood clot) 10 mg subcutaneous (beneath the skin) injection one time only, hold warfarin dose for two days, and repeat the INR test on 11/14/2024. During a review of the Laboratory Services Patient Care Log, the Laboratory Services Log indicated Resident 1 refused to have his blood drawn for his INR level on 11/14/2024 and 11/15/2024. During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 1.18 and was flagged as abnormal (below the INR normal range of 2.0-3.0). During a review of Resident 1's Physician's Order Summary Report dated 11/2024, the Physician's Order Summary Report indicated the following: 1. On 11/19/2024 - Administer Warfarin 4.5 mg in the afternoon every Tuesday, Thursday, and Saturday for Afib, monitor for s/s of bleeding. 2. On 11/19/2024 - Resident 1 may have PT and INR levels drawn every Tuesday and Thursday. 3. On 11/20/2024 - Administer Warfarin 4 mg, give one tablet in the afternoon every Monday, Wednesday, Friday, and Sunday for Afib, monitor for s/s of bleeding. During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 1.12 and was flagged as abnormal. During a review of Resident 1's Nursing Note, dated 11/22/2024 and timed at 8:59 p.m., the Nursing Note indicated Resident 1's laboratory results dated [DATE] were sent to Resident 1's physician. The Nursing Note indicated there was no response from the physician. During a review of Resident 1's Nursing Note dated 11/23/2024 and timed at 7:41 a.m., the Nursing Note indicated the facility refaxed Resident 1's INR results to Resident 1's Physician. The Nursing Note indicated there was no new order, the facility staff endorsed this to the next shift. During a review of Resident 1's Medication Administration Record (MAR) dated 11/2024, the MAR indicated Resident 1's administration of Warfarin as follows: The 9 a.m., dose of Warfarin should have been discontinued, per Resident 1's Physician's NP. 1. On 11/21/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m. and 5 p.m. (a total of 9 mg). 2. On 11/22/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 3. On 11/23/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 5 p.m. (a total of 9 mg). 4. On 11/25/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 5. On 11/29/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 6. On 11/30/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m. and 5 p.m. (a total of 9 mg). During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 6.19 and was flagged as critical. During a review of Resident 1's Progress Note dated 12/2/2024, and timed at 9:38 p.m., the Progress Note indicated Resident 1's INR results of 6.19 were received and sent to Resident 1's physician and the facility was awaiting orders. Resident 1's lab results and the physician's pending response were endorsed to the next shift. There was no physician response. During a review of Resident 1's laboratory results dated [DATE] and timed at 6:58 p.m., the Laboratory results indicated Resident 1's INR was 5.83 and was flagged as critical. During a review of Resident 1's Progress Note dated 12/6/2024 and timed at 4:35 a.m., the Progress Note indicated Resident 1's INR results of 5.83 was relayed to Resident 1's physician, and the staff were waiting for a response. During a review of Resident 1's MAR dated 12/2024, the MAR indicated Warfarin was administered to Resident 1 as follows: The 9 a.m., dose of Warfarin should have been discontinued, per Resident 1's Physician's NP. 1. On 12/1/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 2. On 12/2/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 3. On 12/9/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 4. On 12/10/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 5 p.m. (a total of 9 mg). During a review of Resident 1's Physician's Orders dated 12/11/2024, the Physician's Orders indicated to discontinue administration of Warfarin. During a review of the Resident 1's Physician's Order dated 12/13/2024, the Physician's Order indicated to administer Eliquis (an oral anticoagulant that helps prevent and treat blood clots) 5 mg two times a day for DVT ([deep vein thrombosis] occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs) prophylaxis (preventative treatment against disease). During a review of Resident 1's MAR dated 12/2024, the MAR indicated Resident 1 received Eliquis as ordered from 12/13/2024 thru 12/27/2024. During a review of Resident 1's Nurse's Note dated 12/27/2024, the Nurse's Note indicated Certified Nursing Assistant 1 (CNA 1) observed Resident 1 sitting in a wheelchair, not talking. The Nurse's Note indicated Resident 1 was assessed and 911 emergency services was called. The Nurse's Note indicated Resident 1 was transferred to the GACH for further intervention and assessment. During a review of Resident 1's Physician's Orders dated 12/27/2024, the Physician's Orders indicated to transfer Resident 1 to the nearest GACH via 911 due to unresponsiveness. During a review of the GACH's Emergency Physician's note dated 12/27/2024, the Emergency Physician's note indicated Resident 1 was brought to the GACH via ambulance with a chief complaint of a SDH that measured 12 millimeters ([mm] a unit of measurement). The Emergency Physician's note indicated Resident 1 was intubated and administered Andexxa for reversal of Eliquis. During an interview on 1/2/2025 at 2:04 p.m., and a subsequent interview on 1/3/2025 at 12:15 p.m., Licensed Vocational Nurse (LVN ) 1 stated Resident 1 received multiple doses of Warfarin that overlapped beginning on 11/19/2024. LVN 1 stated when Resident 1's laboratory results indicated his INR level was critically high on 12/2/2024, the results were sent to the physician but there was no follow up by facility's staff when Resident 1's physician did not respond to the fax. LVN 1 stated the staff should have followed up with the physician to determine if the laboratory results were received because the INR values were critically high, and Resident 1 was at risk for bleeding. During an interview on 1/2/2025 at 4:18 p.m., LVN 2 stated all lab results should be reported to the physician and a response from the physician was expected by the end of the shift. LVN 2 stated, if there was no response from the physician by the end of the shift, the lab results should be reported to the MD. During an interview on 1/2/2025 at 4:41 p.m., the NP stated when she revised the Warfarin order to indicate it should be administered to Resident 1 on alternating days of the week (11/19/2024), she instructed LVN 2 to discontinue the order for Warfarin 4.5 mg daily. The NP stated she was not aware Warfarin 4.5 mg daily order was still active. The NP stated Warfarin had a very narrow therapeutic range and Resident 1's INR level could be affected if Warfarin was not administered as ordered and closely monitored. During an interview on 1/4/2025 at 1:18 p.m., the MD stated he had no knowledge that Resident 1's physician had not responded to a report of critical INR levels and was only aware of Resident 1's condition on 12/30/2024, when the GACH reported that Resident 1 sustained an SDH. The MD stated Warfarin was a complicated medication to administer because it involved constant monitoring, blood tests, dose adjustments, and daily monitoring for side effects such as bleeding and bruising. The MD stated if a resident's INR was low, there was a risk that the resident could develop blood clots and if the INR was too high, there was a risk that the resident could develop bleeding. During an interview on 1/4/2025 at 2:08 p.m., the DON stated when administering Warfarin, INR levels should be monitored because if the levels were out of the therapeutic range, residents could be at risk for bleeding or clotting. The DON stated licensed staff should report abnormal lab results to the physician within 24 hours, and critical lab results should be reported to the physician within 4 hours. The DON stated if there was no response from the physician, the MD should be contacted. The DON stated Resident 1's Warfarin 4.5 mg daily order should have been discontinued on 11/19/2024 when the revised Warfarin order was received. During an interview on 1/4/2025 at 2:47 p.m., the ADM stated the licensed nurses documented they administered Warfarin 4.5 mg daily (9 a.m.) in error and they did not administer Warfarin to Resident 1, so Resident 1 could not have received extra doses of Warfarin. During a review of the facility's Policy and Procedure (P/P), titled Administering Medications dated 2001, the P/P indicated medications were administered in accordance with the prescriber's orders, including any required time frame. During a review of the facility's P/P titled Critical Labs of Tests and Diagnostic Procedures-Reporting of dated 1/2/2024, the P/P indicated the response including any new orders/interventions related to the critical results of tests and diagnostic procedures must occur within four (4) hours of reporting of results. The P/P indicated if the Licensed Independent Practitioner ([LIP] a health care provider who is legally permitted to provide care without direct supervision) and or clinician responsible for the resident is not available and that LIP's alternate cannot be reached or is unavailable, the medical director under which the LIP is privileged shall be notified of the critical result.

Based on interview and record review, the facility failed to ensure a resident who had poor safety awareness with a history of an unwitnessed fall from a wheelchair on 1/2/2024, and who required staff supervision with transfers from bed to a wheelchair, did not fall during unassisted and an unsupervised transfers from bed to a wheelchair sustained an injury for one of three sampled residents (Resident 1). The facility failed to: 1. Revise Resident 1's care plan after Resident 1's fall on 1/2/2024 and develop comprehensive person-centered interventions to address Resident 1's poor safety awareness and Resident 1's noncompliance when asking for assistance prior to getting out of bed. 2. Ensure staff did not leave a wheelchair within Resident 1's reach next to the resident's bed, enabling Resident 1 not to call for assistance prior to getting out of bed and transfer unassisted to a wheelchair, causing her falls on 1/2/2024 and 6/2/2024. 3. Ensure staff followed the facility's policy and procedure (P/P) titled Fall and Fall Risk, Managing, which indicated that based on previous evaluations and current data, the staff will identify interventions related to Resident 1's specific risks and causes to try to prevent Resident 1 from falling and to minimize complications from falling. These deficient practices resulted in Resident 1 sustaining a fracture (break in bone) of the left tibia (shin) on 6/2/2024 due to an unsupervised transfer from her bed into a wheelchair on 6/2/2024. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 6/2/2024 for evaluation and treatment of a displaced (gap developed between break in bones) comminuted (bone broken into three of more pieces) oblique (broken at an angle) fracture of left tibia, pain, and decreased mobility. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, difficulty walking, and schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors). During a review of Resident 1's Minimum Data Set ([MDS]) a standardized assessment and care screening tool), dated 3/14/2024, the MDS indicated Resident 1's cognitive skills (thinking process) for daily decision-making were moderately impaired and the resident was able to understand others and was understood by others. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs) with transfers between surfaces, including from bed to a chair and from chair to bed. During a review of Resident 1's Fall Risk Observation/assessment dated [DATE], the Fall Risk Observation/Assessment indicated Resident 1's fall risk score was 18. A score of 16 and above indicated a high risk for falls. During a review of Resident 1's Change of Condition (COC) dated 1/2/2024, the COC indicated on 1/2/2024 at approximately 10 a.m., Resident 1 was found on the floor by a Certified Nursing Assistant (CNA X). During a review of Resident 1's Care Plan, dated 1/2/2024, the Care Plan indicated Resident 1 had an unwitnessed fall (1/2/2024) and was at risk for falls. The Care Plan's goals indicated, to the extent possible, minimize the risk for additional falls and Resident 1 would be compliant with fall interventions to reduce the risk of additional falls. During a review of Resident 1's Fall Risk Observation/Assessment, dated 3/14/2024, the Fall Risk Observation/Assessment indicated Resident 1's fall risk score was 22, indicating a high risk for falls. During a review of Resident 1's Physical Therapy ([PT] treatment used to restore functional movement, such as standing, walking) Discharge Summary, dated 3/8/2024, the PT Discharge Summary indicated Resident 1's functional status for transfers and for gait (the way a person walks) on level surfaces was contact guard assist (care giver places one or two hands on resident's body to help with balance). During a review of Resident 1's COC note, dated 6/2/2024, the COC note indicated on 6/2/2024 at approximately 4:45 a.m., Resident 1 was found on the floor in her room next to her wheelchair by CNA 1. The COC note indicated Resident 1 complained of pain to her left lower leg rated 10 out of 10 on a pain scale from zero to 10 (0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). During a review of Resident 1's Nurse's Notes, dated 6/2/2024, the Nurse's Notes indicated at 4:45 a.m., a noise was noted coming from Resident 1's room. Resident 1 was found on the floor in her room close to her wheelchair. The Nurse's Notes indicated at 5:30 a.m., 911 was called due to Resident 1's uncontrolled pain to her left lower leg, Resident 1 was transferred to a GACH for further evaluation. During a review of the facility's Unusual Incident/Injury report, dated 6/3/2024, the Unusual Incident/Injury report indicated on 6/2/2024 Resident 1 was found lying on the floor on her left side. The Unusual Incident/Injury report indicated Resident 1 reported she was sitting in her wheelchair and was trying to shift her weight because she was not sitting in her wheelchair properly. Resident 1 reported she tried to get up from her wheelchair, but her legs got stuck/twisted and she fell . The Unusual Incident/Injury report indicated Resident 1 was transferred to a GACH (6/2/2024) for further evaluation and on 6/3/2024, the GACH reported Resident 1 sustained a fracture of the left tibia. During a review of Resident 1's Face Sheet, from the GACH, the Face Sheet indicated Resident 1 was admitted to the GACH on 6/2/2024. During a review of Resident 1's History and Physical (H/P), from the GACH, dated 6/2/2024, the H/P indicated Resident 1's Xray result showed Resident 1 sustained a left tibial fracture and she was placed in a long leg splint (an external device used to immobilize an injury or body part). During a review of Resident 1's Imaging report (Xray), from the GACH, dated 6/5/2024, the Xray report indicated Resident 1 sustained a displaced comminuted oblique fracture of the mid to distal third of the left tibia. During an interview on 6/5/2024 at 10:30 p.m., Resident 1 stated a few days ago (6/2/2024), she got out of bed and transferred to her wheelchair. Resident 1 stated she was not steady in her wheelchair and fell from it. Resident 1 stated she was able to get into her wheelchair because her bed was high enough and her wheelchair was at her bedside. Resident 1 stated she does not usually ask for assistance to get out of bed to her wheelchair because she was able to transfer independently, and the nursing staff leaves her wheelchair next to her bedside so she can reach it easily. Resident 1 stated she felt frustrated and uncomfortable because she was in pain and could not get out of bed because of her broken leg. During an interview on 6/6/2024 at 3 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was a high fall risk and should be supervised during transfers from her bed to her wheelchair, but she was noncompliant and did not ask for assistance when transferring. LVN 1 stated, nursing staff often places Resident 1's wheelchair next to her bed within the resident's reach. LVN 1 stated, Resident 1 had poor safety awareness and judgement and placing her wheelchair within reach of her could increase the likelihood that Resident 1 would not call for assistance prior to getting out of bed, causing an increased risk of falls. During an interview on 6/6/2024 at 3:15 p.m., the Director of Rehabilitation (DOR) stated Resident 1 required supervision when transferring out of bed into a chair or wheelchair and back into bed. The DOR stated Resident 1 was a high fall risk and could be unsteady when transferring or ambulating without supervision The DOR stated, the IDT had not revised Resident 1's comprehensive care plans after her fall on 1/2/2024 and prior to her fall on 6/2/2024 to address Resident 1's noncompliance when asking for assistance prior to getting out of bed. The DOR stated, the IDT should have discussed specific interventions to promote safety and prevent future falls. The DOR stated she was not aware the nursing staff was placing Resident 1's wheelchair at her bedside unattended and because Resident 1 had poor judgment and safety awareness, the wheelchair could be considered an environmental hazard and increase Resident 1's risk of falls. During an interview on 6/6/2024 at 4 p.m., the Director of Nursing (DON) stated nursing staff should have ensured Resident 1's care plan interventions (resident needs were anticipated, and the resident was supervised during transfers) were implemented and revised as needed to ensure proper care and services were provided to prevent Resident 1 from falling. The DON stated he was not aware Resident 1's wheelchair was left unattended at the resident's bedside. The DON stated placing the wheelchair next to Resident 1's bed enabled the resident to transfer into the wheelchair unsupervised. The DON stated it was important for staff to supervise Resident 1 during transfers to ensure her safety. During a review of the facility's P/P titled Fall and Fall Risk, Managing, revised 1/2001, the P/P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P/P indicated the staff with the input of the attending physician will implement resident centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The P/P indicated if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. During a review of the facility's P/P titled Safety and Supervision of Residents, revised 7/2017, the P/P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P/P indicated an individualized, resident centered approach to safety, the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Based on interview and record review, the facility failed to ensure, a resident, who lacked the capacity to understand and make decisions, was not discharged from the facility against medical advice ([AMA] choosing to leave the hospital before the treating physician recommends discharge) for one of 141 residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was competent to make a decision to leave the facility and sign out AMA. 2. Ensure Resident 1 had a valid Out On Pass ([OOP] temporary permission given to a resident to leave the facility for a specified amount of time) and AMA order on 4/19/2024, the day Resident 1 wanted to leave. 3. Assess Resident 1's ability to understand his medication regimen in order to safely take his prescribed Haldol (medication for treating schizophrenia [a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others]) for paranoid delusion (profound fear and anxiety [Intense, excessive, and persistent worry and fear about everyday situations] along with the loss of the ability to tell what's real and what's not real) before providing Resident 1 with a total of 41 tablets of Haldol 10 milligrams ([ mg] a unit of measurement of weight) at the time of discharge AMA on 4/19/2024. 4. Ensure there was a referral (preadmission arrangements) made to the shelter before allowing Resident 1 to leave the facility AMA, placing him into a ride-share (a service or network through which ride-sharing trips are arranged) vehicle and sending him to the shelter. 5. Prior to discharge, notify Resident 1's Responsible Party (RP) that Resident 1 was going to sign out of the facility AMA and would be going to a shelter on 4/19/2024. These deficient practices resulted in Resident 1 leaving the facility without prior arrangements, to the shelter of his choice. Resident 1 was not accepted by the shelter upon Resident 1's arrival to the shelter and is now missing. Resident 1's whereabouts are currently unknown. These failures placed Resident 1 at a high risk for exposure to harsh environmental conditions, possible motor vehicle accidents, and medical complications due to taking antipsychotic medications (medications work by altering brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking) inappropriately, or overdosing (too much of a drug taken or given at one time), malnutrition (lack of proper nutrition), heart failure, chronic kidney disease complications, dehydration (body doesn't have as much fluid as it needs), and possible death. On 4/26/2024 at 3:02 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to a resident) related to failure to safely discharge a psychiatric resident (Resident 1) with a 20-days supply of medications without assessing the resident's ability to self-administer his prescribed antipsychotic (medication that affects the brain) medication was called in the presence of the Administrator, the Director of Nursing (DON) and two outside Resource Registered Nurses. The facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed on 5/1/2024 at 8:41 a.m., in the presence of the temporary manager and Assistant Director of Nursing (ADON). The IJRP included the following: 1.On 4/26/2024 the Medical Director reviewed and approved the updated changes to the Policy and Procedure for Out on Pass, to include, residents' discharge, and measures to take if a resident is out on pass and refuses to return to the facility on [DATE]. 2.The Medical Director approved the updated changes to the Policy and Procedure for Discharging a Resident Without a Physician's approval (Against Medical Advice-AMA) on April 30, 2024. 3.The facility began In-service (education) training for Social Services and Licensed Nurses on Policies and Procedures for the following; Out On Pass, Safe Discharge AMA, beginning on April 30, 2024, by the Director of Nursing/Designee to be completed when employees return to work according to their schedule. 4.At the time of admission, the physician will make the decision regarding the capacity (ability of the resident to make decisions). The results of the capacity determination will identify if the resident is responsible for decision making. The facility will ascertain if the resident has a responsible party or not, prior to admission. A new policy and procedure will be implemented for capacity. The Admission Packet includes the resident's capacity for making decisions and the responsible party who signs on behalf of the resident. 5.Physicians will be asked to reassess their residents' capacity status as needed. 6.The Out On Pass Policy was updated to state that if a resident is refusing to return to the facility from out on pass activity, residents' responsible party, primary MD and Psychiatrist will be notified. 7.Every effort will be made by the staff to assist the resident to return to the facility. They will have a conversation with the resident on why they do not want to return to the facility. Social Services, the Administrator and Director of Nursing will be notified. 8.If the resident is suspected to be a danger to self or others appropriate authorities will be notified to determine if a 5150 hold (an involuntary hold of a person who is deemed to be a danger to themself, a danger to others, or gravely disabled, as a result of a mental disorder, for psychiatric evaluation, assessment, and/or treatment) will be placed and the resident will be transferred to a psychiatric (mental illness) acute (sudden) care hospital for further evaluation. If the resident is determined not to be a danger to self or others, he/she will be educated on the risks and benefits of leaving the facility against medical advice (AMA). As, it is the Residents Right to leave the facility AMA, the staff will follow guidelines of AMA policy and procedure. 9. The facility began In-service training for Social Services staff and Licensed Nurses on Policies and Procedures for the following; Out On Pass, Safe Discharge AMA, beginning on April 30, 2024, by the Director of Nursing/Designee to be completed as employees return to work according to their schedule. 10. A facility wide Capacity/Responsible Party (a person that would make decisions for Residents that cannot safely make their own decisions) audit was conducted on April 26, 2024, to determine if there were any other residents found to have unknown responsibility status. At this time all residents have capacity identified and the Responsible Party identified. An audit was conducted by Social Services for other residents if they have fluctuating capacity (a person whose decision-making ability varies). 18 residents were identified with fluctuating capacity. Out of the 18 identified, six residents did not have capacity status (to make decisions); they were referred to the public guardian (a public official that is responsible for the care of individuals who are no longer able to make decisions or care for themselves). Four of those are still being processed and two have been processed and will move forward through the public guardian appointing process. Their physicians will be notified to reassess if they have capacity to make decisions on a quarterly basis. 11. The care plans for those residents with fluctuating or no capacity will be revised to reflect the residents' capacity by Friday May 3rd, 2024. 12.The resident's physician will be notified of the request for AMA discharge. The physician will determine the need to release the resident AMA with or without medications. If the resident does not have capacity, they will not be sent with medications unless there is a Responsible Party present to take responsibility for the medication. If the resident is released with medications and it is expected that they will self-administer those medications, an assessment of the resident, will be conducted by the nursing staff to assure they have the ability to accurately self-administer those medications. 13. Any resident who discharges AMA will be trained on self- administration of medications before they leave the facility. A Discharge Summary will be given to the resident with the directions for taking the medications. The resident will sign the Discharge Summary indicating that they have received self-medication administration training and understand the risks and benefits of taking the medications correctly. The facility staff will also sign the Discharge Summary, witnessing the resident's signature. The progress note will include all steps taken to foster the resident's highest practicable wellbeing because of the resident going out of the facility AMA. 14. Licensed nurses will be in-serviced on the policy and procedure for self-administration of medications, training on self-administration of medications and disposition of remaining medications beginning on April 30, 2024, by the Director of Nursing/Designee using the teach back method by May 3rd, 2024, or upon their next scheduled shift. Medications not given to the resident upon AMA discharge will be disposed of according to State and Federal regulations. 15. The facility will ensure that any resident who leaves the facility AMA is given the best chance possible of succeeding outside of the facility by notifying the receiving facility, including shelters, the resident has requested to move to and that the shelter would be able to meet their needs. Social Services and licensed nurses will be in-serviced on notifying the intended location, assuring availability and capability to meet resident needs. Social Services will be responsible for notifying any shelter of the resident's request. Social Services will be in-serviced on Discharging a Resident Without a Physician's approval (Against Medical Advice-AMA) beginning on April 30, 2024, by the Director of Nursing/Designee to be completed by May 3rd, 2024. 16. Social Services will be responsible for follow-up on any resident who went AMA to see if they arrived at their intended location, where practicable. Social Services and Licensed nurses will be in-serviced beginning on April 30, 2024, by the Director of Nursing/Designee to be completed by May 3rd, 2024. 17. The facility has begun an audit of all residents with the inability to make decisions. Conservators (a person who looks after and is legally responsible for someone who is unable to manage their own affairs)/Responsible Party will be notified if one of their residents tries to seek a discharge (AMA). That is the conservator's/ Responsible Party's responsibility to make that decision. The facility will follow the conservators' decisions. The facility will follow its' policies and procedures for AMA Discharge and notification of Responsible Parties pending AMA discharge. 18. Action Plans to manage reoccurrences of leaving the facility against medical advice (AMA) will be implemented in the Quality Assurance and Performance Improvement Committee ([QAPI] a facility committee consisting of department heads, the medical director, physicians and key staff that identifies system failures by data gathering and analysis and implements measure to improve the overall quality of life and quality of care and services delivered to nursing home residents.) on April 29, 2024. Findings: During a review of Resident 1's General Acute Care Hospital (GACH 1) Behavioral Health Progress Note dated 2/25/2024, the Behavioral Health Progress Note indicated, Resident 1 exhibited signs of paranoia (unjustified suspicion and mistrust of other people and/or their actions) and was brought to GACH 1 from a jail, with disorganized thoughts, and poor insight. The Behavioral Health Progress Note indicated Resident 1 was a poor historian, unkempt (having an untidy appearance), malodorous (an unpleasant or offensive odor), and with disorganized speech, and on a 5150 hold. The Behavioral Health Progress Note indicated Resident 1 had two recent psychiatric evaluations in the past two months and ongoing intractable (not easily controlled or directed) psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). During a review of Resident 1's Order Summary Report (OSR), from the SNF, dated 4/24/2024, the OSR indicated, to admit Resident 1 to the facility on [DATE]. During a review of Resident 1's Skilled Nursing Facility (SNF) Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia, congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), myocardial infarction ([heart attack] when the heart muscle begins to die because it isn't getting enough blood flow), anxiety disorder, obstructive sleep apnea (a disorder in which a person frequently stops breathing during his or her sleep), and essential hypertension ([HTN] abnormally high blood pressure that's not the result of a medical condition). During a review of Resident 1's History and Physical (H&P), dated 3/15/2024, the H&P indicated, Resident 1 had a fluctuating capacity to make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/20/2024, the MDS indicated Resident 1 required assistance (helper does all of the effort) from one staff for toilet use, hygiene, lower body dressing, putting on/taking off footwear, bed mobility, and transfers. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) from one staff for personal hygiene, moderate assistance (helper does less than half the effort) from one staff for upper body dressing, oral hygiene, rolling from left to right, and supervised touch assistance (helper provides verbal cues/touching/steadying/contact guard assistance) from one staff for eating and showering. During a review of Resident 1's Change in Condition Evaluation/Change of Condition (COC) dated 3/4/2024 and timed at 6 p.m., the COC indicated, upon admission Resident 1 was verbally aggressive and attempted to strike at staff and was requesting to leave the facility. The COC indicated a physician's order was obtained to transfer Resident 1 on a 5150 hold to GACH 2 for further evaluation. During a review of Resident 1's Order Summary Report dated 4/24/2024, the OSR indicated, a physician's order dated 3/4/2024 to transfer Resident 1 to GACH 2 for evaluation and treatment related to paranoid delusion. During a review of Resident 1's GACH 2 H&P, dated 3/5/2024, the H&P indicated, Resident 1 was brought to GACH 2's emergency department (ED) on a 5150 hold for further treatment, after developing acute agitation and striking out at staff members. During a review of Resident 1's Order Summary Report, from the SNF, dated 4/24/2024, the Order Summary Report indicated, a physician's order dated 3/13/2024 to admit Resident 1 to the facility. During a review of Resident 1's Summary of Neurobehavioral and Cognitive (an assessment of a wide range of mental functions, including behavior, to see how well the brain works) consult, dated 4/12/2024, the Neurobehavioral Summary indicated Resident 1 was partially oriented (he did not know the month and the year), with partial awareness of his location, and was unable to express himself verbally. The Summary Neurobehavioral Consult note indicated Resident 1 had difficulty making complex decisions and the help of a designated decision-maker was recommended. During a review of Resident 1's Interdisciplinary Team [([IDT] - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the resident) Conference Notes, dated 3/13/2024, the IDT Conference Notes indicated, Resident 1 was to remain in the facility at this time. The IDT Conference Notes indicated Resident 1 wished to transition back to community and he would be referred to ancillary (supportive or diagnostic measures that supplement and support a primary healthcare provider in treating a patient) services and psychology for follow up. During a review of Resident 1's Order Summary Report dated, 4/24/2024, the Order Summary Report indicated a physicians' order dated 3/13/2024 to give Haldol 10 mg, one tablet by mouth, two times a day for schizophrenia manifested by paranoid delusions. During a review of Resident 1's Order Summary Report dated, 4/24/2024, the Order Summary Report indicated a physician's order dated 3/31/2024 to give Ativan one mg, one tablet by mouth, every six hours as needed for anxiety disorder for 14 days as manifested by the inability to relax. During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated Resident 1 received Ativan 1 mg for anxiety on the following days: 1. 3/15/2024 at 4:15 p.m. 2. 3/16/2024 at 6:00 p.m. 3. 3/17/2024 at 9:56 p.m. and 6:00 p.m. 4. 3/18/2024 at 10:01a.m. and 6:05 p.m. 5. 3/20/2024 at 5:15 p.m. 6. 3/21/2024 at 5:20 p.m. 7. 3/22/2024 at 5:30 p.m. 8. 3/23/2024 at 6:00 p.m. 9. 3/24/2024 at 5:03 p.m. 10. 3/27/2024 at 5:00 p.m. 10. 4/2/2024 at 4:27 p.m. 11. 4/5/2024 at 4:27 p.m. 12. 4/11/2024 at 9:28 p.m. During a review of Resident 1's Self-Administration of Medication observation form, dated 3/13/2024, the Self-Administration of Medication Observation form indicated, Resident 1 did not want to self-administer medication. During a review of Resident 1's OOP order, created by the Assistant Director of Nurses (ADON) on 4/19/2024 and a back -date (to date the order earlier than it was actually given) of 3/20/2024, the OOP order indicated Resident 1 could leave the facility on a therapeutic pass, in the company of a facility staff member for safety and supervision. During a review of Resident 1's AMA order, created by the Director of Nursing (DON) on 4/22/2024 (back-dated three days after Resident 1 left the facility AMA), the AMA order indicated Resident 1 may be discharged from the facility AMA on 4/19/2024. During a review of Resident 1's clinical record, the clinical record indicated there was no OOP order on 4/19/2024 (the day Resident 1 was accompanied by facility staff OOP). During a review of Resident 1's Ride-Share receipt, dated 4/19/2024, the Ride Share receipt indicated Resident 1 was picked up at the bus stop near the sidewalk of the fast-food restaurant at 1:52 p.m., and arrived at the destination (shelter) at 2:10 p.m. During a review of Resident 1's Social Service Notes (SSN), dated 4/23/2024 and timed 9:50 p.m., the SSN indicated, the Social Service Director (SSD) contacted the shelter Resident 1 was sent to, and spoke to the shelter coordinator. The SSN indicated the shelter coordinator stated there was no record of Resident 1 checking in to the shelter as of 4/19/2024. During an interview on 4/23/2024, at 3:40 p.m., the SSD stated he was not informed that Resident 1 signed out of the facility AMA until after the incident. The SSD stated, many shelters required a referral due to limited space and had he known Resident 1 was being discharged from the facility he could have assisted him to find a place to transfer to. The SSD stated he should have followed up with the shelter Resident 1 was transferred to, to make sure Resident 1 arrived and was admitted there. The SSD stated, some shelters could assist residents with limited medical care, he did not know if the shelter that Resident 1 was sent to could accommodate Resident 1's medical needs or if they would administer Resident 1's medications. The SSD stated there was no discharge plan for Resident 1 because Resident 1 had been transferred in and out of the facility to the GACH on a 5150 hold because of behavioral issues. During an interview on 4/23/2024, at 4:03 p.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 was usually quiet and cooperative, but there were times when he became verbally aggressive and paranoid. LVN 1 stated that was why Resident 1 was on routine (scheduled) Haldol and as needed Ativan. LVN 1 stated, Resident 1 had a history of noncompliance with taking his medication, and his daily medications were administered by the licensed nurses at the facility and Resident 1 never expressed a desire to self-administer his medications. During an interview on 4/23/2024, at 4:41 p.m., Registered Nurse Supervisor 1 (RNS 1) stated, Resident 1 was transferred to GACH 2 on 3/4/2024 because of aggressive behavior and was readmitted to the facility on [DATE] to a secured unit (a unit in a nursing home that restricts a resident's ability to freely move in and out of ) for behavior monitoring, but was transferred from the secured unit to a skilled nursing unit (non-secured unit with less intense monitoring for behavior issues and focuses on medical and rehabilitation treatment) on 4/16/2024. RNS 1 stated Resident 1 had a fluctuating mental capacity, and he might not understand the risks of AMA and stated she was not sure if Resident 1 was safe to leave the facility AMA. During a telephone interview on 4/24/2024, at 8:46 a.m., Family Member (FM 1) stated, no one at the facility called to notify her that Resident 1 wanted to leave the facility or that Resident 1 left the facility AMA. FM 1 stated, Resident 1 was not in his right mind, and she could not understand how the facility let Resident 1 leave the facility even if he wanted to go, or how the sheriff, who were not medical professionals, could assess someone's mental capacity. During an interview on 4/24/2024, at 10:49 a.m., the ADON stated he took Resident 1 OOP on 4/19/2024 to a fast-food restaurant across the street from the facility. The ADON stated, after Resident 1 ordered and got some food Resident 1 started walking outside of the fast-food restaurant and refused to go back to the facility. The ADON stated, he notified the DON, the Administrator (ADM), and a Registered Nurse that worked with a temporary management team (TMRN 1) that was contracted with and stationed at the facility. The ADON stated TMRN 1 instructed him to call the local sheriff department to evaluate Resident 1 for a 5150 hold, to notify Resident 1's psychiatric (Psychiatrists are trained physicians who specialize in evaluating, diagnosing and treating mental disorders) doctor and follow whatever the psychiatrist asked him to do. During an interview on 4/24/2024, at 11:00 a.m., the ADON stated, he spoke to Resident 1's psychiatrist via the telephone and received an order from him to sign Resident 1 out AMA if the sheriff did not place Resident 1 on a 5150 hold. The ADON stated, the sheriff reported that Resident 1 did not meet the criteria for a 5150 hold, so he (ADON) believed Resident 1 was safe to be discharged AMA, as instructed by Resident 1's psychiatrist. The ADON stated, there was an order in place on 4/16/2024 which indicated Resident 1 could go out to the courtyard (which was an outside common area on facility grounds surrounded by the facility buildings) for therapeutic services. The ADON stated, the fast-food restaurant was across the street from the facility, so he took Resident 1 to the fast-food restaurant. The ADON stated he did not assess Resident 1's behavior prior to taking him across the street to the fast-food restaurant to determine if it was safe for him to go OOP that day. During an interview on 4/24/2024, at 11:15 a.m., the ADON stated, he did not know the shelter (Resident 1 chose to go to) required a referral and thought anyone could just walk in and get accepted, nor did he follow up with the shelter to see if Resident 1 arrived there safely. The ADON stated he should have consulted with the SSD for Resident 1's placement, but he did not, and he did not call FM 1 or FM 2 during the process prior to Resident 1 leaving AMA, he only left a message with FM 1 after Resident 1 had already left the facility AMA. The ADON stated he did not notify FM 1 or FM 2 that Resident 1 was not accepted at the shelter or that Resident 1's current location was unknown because he did not follow up with the shelter and did not know Resident 1 was not there. During a telephone interview on 4/24/2024, at 11:29 a.m., Resident 1's psychiatrist stated, he did not think Resident 1 had the capacity to make decisions, but it did not matter whether he had capacity or not, it was his right to leave AMA if the sheriff did not place him on a 5150 hold. Resident 1's psychiatrist stated he told the facility to give Resident 1 a 10 day-supply of Haldol 10 mg tablets because he did not want Resident 1's medication to be stopped abruptly to prevent relapse (reoccurrence) of psychosis (a severe mental condition in which thoughts and emotions are so affected and contact is lost with reality). Resident 1's psychiatrist stated there was the risk of overdose if Resident 1 took to many Haldol tablets, which could lead to arrythmia (a condition in which the heart beats with an irregular or abnormal rhythm which may increase the risk for a serious heart condition). During an interview on 4/24/2024, at 11:44 a.m., LVN 3 stated, she received a call from the ADON asking her to bring an AMA form and all Resident 1's medications to the sidewalk near the fast-food restaurant. LVN 3 stated she gave all of Resident 1's medications and AMA form for Resident 1 to sign, to the ADON. During a telephone interview on 4/24/2024, at 11:56 a.m., the Referral Agent (RA) at the shelter Resident 1 was sent to stated, Resident 1 showed up at the shelter on 4/19/2024, but they could not admit him because he did not have a referral from the facility, he came from, prior to arriving at the shelter and they only accept walk-ins if they had enough beds available. The RA stated Resident 1 came in after 2 p.m., when available beds had already been assigned by that time. The RA stated Resident 1 left the shelter after he was told he could not check in and he (RA) did not know where Resident 1 went or his whereabouts. During an interview on 4/24/2024, at 1:48 p.m., the DON stated he was not sure if there was an OOP order for Resident 1 prior to 4/19/2024 and he did not create an AMA order until after Resident 1 left the facility (4/22/2024) because he got busy and forgot to do it. The DON stated, he received a call from the ADON on 4/19/2024 regarding Resident 1's refusal to come back to the facility. The DON stated he went with the ADM to the sidewalk of the fast-food restaurant to assist the ADON with discharging Resident 1. The DON stated, he gave Resident 1 a total of 41 tablets of Haldol 10 mg which was a 10-day supply. (According to the Resident 1's physicians' order dated 3/13/2024 to administer Haldol 10 mg, one tablet by mouth, two times a day for schizophrenia manifested by paranoid delusions, the DON gave Resident 1 a 20-day supply of Haldol). During an interview on 4/24/2024, at 2:00 p.m., the DON stated, he did not check Resident 1's Self-Administration of Medication Assessment nor did he give Resident 1 written instructions related to his Haldol. The DON stated Resident 1 responded OK when he showed him the instructions on the Haldol package on how to take his medication. The DON stated, he forgot to document Resident 1's medication order to give Resident 1 a 10-day supply of Haldol on the eMAR (a digital version of the MAR), or in Resident 1's Medication Disposition Log (any medication dispositioned or supplied to the resident should be documented on medication disposition log for record keeping). During an interview on 4/24/2024, at 2:05 p.m., the DON stated, he did not know if anyone at the shelter would supervise Resident 1's Haldol self-administration. The DON stated, Resident 1 could be at risk for overdose if he took to many of the Haldol tablets at one time or his symptoms could worsen if Resident 1 did not take the Haldol. The DON stated, it was not safe to discharge Resident 1 but Resident 1 was the one who made the decision to leave the facility AMA. The DON stated, he did not know the shelter required a referral from the facility for Resident 1 to be admitted , had he known that he would have called the shelter with a referral to have Resident 1 admitted . The DON stated, he was not familiar with the facility's AMA policy for residents with mental illness. During a telephone interview on 4/24/2024, at 6:25 p.m., FM 1 stated, Resident 1 had been suffering from mental illness and other medical conditions for over [AGE] years and had been in and out of hospitals all of those years for his behaviors. FM 1 stated she received a voice-message from facility staff during the evening of 4/19/2024, when she called back the next morning (4/20/2024) the facility nurse told her Resident 1 left the faciity on [DATE] because he did not want to stay at the facility. FM 1 stated, the facility did not tell her Resident 1 was not accepted to the shelter he was sent to, and that his whereabouts were unknown. FM 1 stated she was scared that Resident 1 would harm himself or someone else, based on her previous experience with him, and she was worried about his safety. During an interview on 4/25/2024, at 4:42 p.m., the ADM stated, he received a call from the ADON that Resident 1 refused to come back to the facility while her and Resident 1 were OOP at a fast-food restaurant across the street from the facility. The ADM stated, they followed the instructions of Resident 1's psychiatrist and TMRN 1 to discharge Resident 1 AMA. The ADM stated, they could have done better, but the situation was very intense at that time, and they did not have all of Resident 1's previous psychiatric history. The ADM stated, they should have contacted the SSD to arrange placement for Resident 1 before discharging him AMA and they should have followed up with the shelter to see if Resident 1 was admitted . The ADM stated their policy was not very clear about the process and requirements for AMA. During a telephone interview on 4/27/2024, at 9:51 a.m., Resident 1's psychologist (a person who specializes in the treatment of mental, emotional, and behavioral disorders without prescribing medications) stated, he was not aware that Resident 1 was released from the facility AMA. Resident 1's psychologist stated Resident 1 could not make complex decisions and he was concerned Resident 1 would become noncompliant with his care and not take his medication as he had done in the past, which would make his condition worse. During a review of the facility's P&P titled, Transfer or Discharge, Emergency, revised 8/2018, the P&P indicated, should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will notify the resident's attending physician, notify the receiving facility that the transfer is being made, notify the representative (sponsor) or other family member. During a review of the facility's P&P titled, Discharging a Resident Without a Physician's Approval, revised 10/2022, the P&P indicated, if a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and will discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location, document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed, document that despite being [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the resident, who had no impairments in the right hand and arm range of motion ([ROM], full movement potential of a joint [where two bones meet]) did not acquire an avoidable decline (reduction) in ROM and did not developed a contracture of the right hand including fingers for one of five sampled residents (Resident 110). The facility failed to: 1. Consistently apply a splint (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) to Resident 110's right hand from 9/12/2023 to 12/5/2023, for a total of three months. 2. Ensure Resident 110 used the dominant (the hand usually used during completion of tasks of daily living such as eating, and brushing teeth) right hand for self-feeding (instead of the left hand) with built-up utensils (specialized utensils with larger handles to improve grasp) beginning 9/12/2023 to maintain ROM on the right arm and hand. 3. Ensure Resident 110 received Tylenol (Acetaminophen, pain reliever) 650 milligrams ([mg], a unit of weight measurement) for pain prior to the Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)]Evaluation on 9/12/2023 and prior to OT Treatments of the right-hand from 9/2023 to 11/2023. 4. Ensure Resident 110's right hand ROM was assessed during the OT's Evaluation and Plan of Treatment assessment on 9/12/2023. 5. Ensure the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, was followed by having interventions including therapies, provision of necessary equipment, and/or exercises to prevent resident 110's decline in ROM and the development of right-hand contracture. These failures resulted in Resident 110 developing pain, stiffness, and decreased ROM throughout the right, dominant arm, preventing Resident 110 from using the right hand for activities of daily living ([ADLs], tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), contributing to Resident 110's feelings of hopelessness and preventing Resident 110 from living at his highest practicable wellbeing. (Cross reference F580) Findings: During a review of Resident 110's Admission Record, the Admission Record indicated Resident 110 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis (a condition where damaged muscle tissue releases a substance into the bloodstream which can damage the kidneys), muscle weakness, adult failure to thrive (condition where an adult experiences inadequate nutrition), unspecified dementia (a decline in mental ability severe enough to interfere with daily life) with agitation (feeling of anxiety or irritability) and with gastrostomy ([G-tube], a soft tube surgically inserted directly in the stomach for administration of nutrition and medication) tube in place. During a review of Resident 110's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 6/3/2023, the MDS indicated Resident 110 had no speech, rarely expressed ideas, and wants, rarely understood verbal content, and had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 110 required extensive assistance (resident involved in activity with staff support) from staff with dressing and personal hygiene and total dependent (full staff assistance) with eating. The MDS also indicated Resident 110 did not have any impairments in ROM to both arms and both legs. During a review of Resident 110's OT Evaluation and Plan of Treatment, dated 6/1/2023 signed by Occupational Therapist 2 (OT 2), the OT Evaluation indicated Resident 110 had sufficient movement in ROM without significant limitation (WFL) in both arms and did not have any contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in either arm. The OT Evaluation indicated Resident 110 was totally dependent (required more than 75 percent [%] physical assistance to perform the task) for hygiene, grooming, and upper body dressing. The OT Plan of Treatment included therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular (relating to the nerves and muscles) reeducation (a technique used to restore movement patterns through repetitive motion to retrain the brain), therapeutic activities (tasks that improve the ability to perform activities of daily living [ADL's] and self-care management training five times per week for four weeks. During a review of Resident 110's Change of Condition ([COC], documentation regarding important medical information due to a change from normal state of being) Evaluation, signed on 6/23/2023, the COC Evaluation indicated Resident 110 had a dislodged (forced out of position) G-tube on 6/15/2023. The COC Evaluation indicated Resident 110's primary physician was notified and ordered to transfer Resident 110 to the hospital for G-tube reinsertion. During a review of Resident 110's OT's Discharge Summary, dated 6/22/2023, the OT's Discharge Summary indicated Resident 110 was discharged to the hospital. During a review of Resident 110's Admission Record, the Admission Record indicated the facility readmitted Resident 110 on 6/26/2023. During a review of Resident 110's medical record, the record indicated a physician's order, dated 6/27/2023, for 650 milligrams ([mg], a unit of weight measure ment) of Tylenol (Acetaminophen, pain reliever) through the G-tube every four hours as needed for pain. During a review of Resident 110's Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 6/27/2023 (after readmission) signed by Occupational Therapist (OT 1), the OT Evaluation and Plan of Treatment indicated Resident 110 had impaired ROM to both shoulders but had active range of motion ([AROM], performance of ROM of a joint without any assistance or effort of another person) to lift both arms above shoulder height. The OT Evaluation indicated Resident 110 did not have any contractures and the ROM in both of Resident 110's elbows, forearms, wrists, and hands were WFL. The OT Evaluation indicated Resident 110's ability to self-feed was not assessed due to the presence of a G-tube and required maximal assistance (required 50 to 75% physical assistance to perform the task) with two persons for hygiene, grooming, and upper body dressing. The OT Evaluation included a goal for Resident 110 to perform hygiene and grooming tasking with maximal assistance at the edge of bed. The OT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training five times per week for four weeks. During a review of Resident 110's OT Treatment Encounter Note, dated 7/6/2023 signed by Certified Occupational Therapy Assistant 1 (COTA 1), the OT Treatment Encounter Note indicated COTA 1 placed a hand towel roll (rolled up hand towel) to Resident 110's right hand to improve contractures to the (unspecified) fingers. The Treatment Encounter Note indicated Resident 110 was unable to open the right hand due to finger contractures and had difficulty with handling objects with the right hand due to tightness in the fingers. During a review of Resident 110's OT Progress Report, dated 7/10/2023 signed by OT 1, the OT Progress Report indicated Resident 110 was treated for five days during the 7/4/2023 to 7/10/2023 progress period. The OT Progress Report did not indicate Resident 110 had a decline in right hand ROM. During a review of Resident 110's OT Treatment Encounter Note, dated 7/11/2023 signed by COTA 1, the OT Treatment Encounter Note indicated Resident 110 had a right-hand contracture which affected Resident 110's ability to perform hygiene and grooming. The OT Treatment Encounter Note indicated COTA 1 educated Resident 110 in (unspecified) compensatory techniques (learning a new or different way to complete a task) to perform hygiene and grooming. During a review of Resident 110's OT Progress Report, dated 7/17/2023 signed by OT 1, the OT Progress Report indicated Resident 110 was treated for five days during the 7/11/2023 to 7/17/2023 progress period. The OT Progress Report did not indicate Resident 110 had a decline in right hand ROM. The OT Progress Report included a new OT goal for Resident 110 to perform self-feeding tasks with supervision (required verbal cues but no physical assistance to perform task) using built-up utensils. During a review of Resident 110's OT Treatment Encounter Note, dated 7/20/2023 signed by COTA 1, the OT Treatment Encounter Note indicated Resident 110 had finger contractures in the right hand which required stretching and a rolled hand towel to increase finger ROM. During a review of the Rehabilitation - Joint Mobility Screening (passive range of motion [{PROM}, movement of joint through the ROM with no effort from the person] assessment of the joints), dated 7/21/2023 signed by the Clinical Resource Therapist (CRT), the Rehabilitation-Joint Mobility Screening indicated Resident 110 had WFL PROM in all joints except minimal ROM impairment (approximately 75% of full ROM) in the right shoulder and severe ROM impairment (25% or less of full ROM) in the right hand. During a review of Resident 110's OT Treatment Encounter Note, dated 7/21/2023 signed by Occupational Therapist 2 (OT 2), the OT Treatment Encounter Note indicated OT 2 placed a hand towel in Resident 110's right hand due to tightness and difficulty extending fingers. During a review of Resident 110's OT Recertification Progress Report, and Updated Treatment Plan (OT Recertification, assessment to justify a person's continued need to receive services), dated 7/25/2023 signed by OT 1, the OT Recertification indicated a continued OT goal for Resident 110 to perform self-feeding tasks with supervision using built-up utensils. During a review of Resident 110's OT Treatment Encounter Note, dated 7/25/2023 signed by OT 1, the OT Treatment Encounter Note indicated Resident 110 had an increased muscle tightness in the right hand. The OT Treatment Encounter Note indicated OT 1 verbally communicated Resident 110's about increased muscle tightness and need for a right-hand splint to the Assistant Director of Rehabilitation (ADOR). During a review of Resident 110's OT Treatment Encounter Note, dated 7/27/2023 signed by OT 1, the OT Treatment Encounter Note indicated OT 1 spoke with the prosthetist (professional who customizes medical devices) in person regarding Resident 110's need for a right-hand splint. During a review of Resident 110's OT Treatment Encounter Note, dated 8/1/2023 signed by COTA 2, the OT Treatment Encounter Note indicated Resident 110 received a carrot splint (device shaped like a carrot with one side thicker than the other to position the fingers away from the palm to protect the skin from moisture, pressure, and nail puncture) for the right-hand. During a review of Resident 110's OT Therapy Progress Report, dated 8/7/2023 signed by OT 1, the OT Therapy Progress Report indicated Resident 110 was seen for five days during the 8/1/2023 to 8/7/2023 progress period. The OT Progress Report indicated Resident 110 demonstrated good tolerance to the hand roll splint on the right hand and included a new OT goal to wear a hand roll on the right hand for up to four hours. During a review of Resident 110's OT Recertification, dated 8/22/2023 signed by OT 1, the OT Recertification indicated continued OT goals for Resident 110 to wear a hand roll on the right hand for up to four hours and to perform self-feeding tasks with supervision using built-up utensils. During a review of Resident 110's MDS, dated [DATE], the MDS indicated Resident 110 had clear speech, usually expressed ideas, and wants, usually understood verbal content, and had severely impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 110 required extensive assistance for eating and personal hygiene. The MDS indicated Resident 110 had ROM impairments in one arm and no impairments to both legs. During a review of Resident 110's OT Treatment Encounter Note, dated 9/8/2023, the Encounter Note indicated Resident 110 tolerated the carrot splint to the right hand for two-and-a-half hours. During a review of Resident 110's OT Discharge Summary, dated 9/11/2023, the OT Discharge Summary indicated Resident 110 required minimal assistance for self-feeding using built-up utensils and tolerated a right-hand splint for two hours. Resident 110's OT Discharge Summary did not include ROM assessments of both arms. The OT Discharge Summary indicated the reason for Resident 110's discharge from OT was a change in payor source. During a review of the OT Evaluation and Plan of Treatment, dated 9/12/2023 signed by OT 2, the OT Evaluation indicated both of Resident 110's shoulders had impaired ROM with the right arm more affected than the left. The OT Evaluation indicated Resident 110's right hand ROM was impaired, but Resident 110 did not allow any movement to the right hand due to complaints of pain. The OT Evaluation indicated nursing was notified regarding Resident 110's pain but did not indicate whether Resident 110 received any pain medication. The OT Evaluation indicated Resident 110 required minimal assistance for self-feeding, and a new OT Goal included for Resident 110 to perform self-feeding with supervision. The OT Evaluation did not include for Resident 110 to use built-up utensils for self-feeding and did not include the use of a right-hand splint. The OT Plan of Treatment for Resident 110 included therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training four times per week for four weeks. During a review of Resident 110's Medication Administration Records (MARs) from 6/2023 to 11/2023, the MAR indicated Tylenol (Acetaminophen) was not administered. During a review of Resident 110's physician's orders, the physician's orders indicated an order, dated 10/11/2023, for a Regular diet, pureed texture (pudding like consistency that does not require chewing) with thin liquids consistency. Provide extra three to four ounces ([oz] unit of weight) of fluids with meals. During a review of Resident 110's OT Treatment Encounter Notes, dated 9/12/2023, 9/13/2023, 9/16/2023, and 9/18/2023, the OT Treatment Encounter Notes did not include the application of a right-hand carrot splint. During a review of the OT Treatment Encounter Note, dated 9/18/2023, the OT Treatment Encounter Note indicated Resident 110 refused ROM to the right wrist and fingers due to fear of pain. The OT Treatment Encounter Note did not indicate Resident 110 received pain medication. During a review of Resident 110's OT Treatment Encounter Note, dated 9/19/2023, the OT Encounter note indicated Resident 110 was protective and guarding (cautious with resistance, protecting against pain) the right hand throughout the treatment session. The OT Encounter Note indicated the right index fingernail was digging into the palm near the thumb, requiring nail clipping. The OT Encounter Note indicated Resident 110 was encouraged to use the left (non-dominant) hand for hygiene to clean the right hand using a wipe and had a carrot splint applied to the right hand for two-and-a-half hours. The OT Treatment Encounter Note did not indicate Resident 110 received pain medication. During a review of Resident 110's OT Treatment Encounter Notes, dated 9/20/2023, 9/21/2023, 9/22/2023, 9/26/2023, 9/27/2023, 9/29/2023, 10/3/2023, 10/4/2023, 10/5/2023, 10/9/2023, and 10/10/2023, the OT Encounter Notes did not include the application of a right-hand carrot splint. During a review of Resident 110's OT Recertification, dated 10/10/2023, the OT Recertification indicated Resident 110 continued to require minimal assistance for self-feeding. Resident 110's OT Recertification included an OT goal for Resident 110 to perform self-feeding with contact guard assistance (required steadying assistance to complete task). The OT Recertification did not include for Resident 110 to use built-up utensils for self-feeding and did not include the use of a right-hand splint. The OT Plan of Treatment for Resident 110 included therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training four times per week for four weeks. During a review of Resident 110's OT Treatment Encounter Note, dated 10/11/2023, the OT Treatment Encounter Note did not include the application of a right-hand carrot splint. During a review of Resident 110's OT Treatment Encounter Note, dated 10/12/2023, the OT Treatment Encounter note indicated Resident 110 refused the right-hand carrot splint. During a review of Resident 110's OT Treatment Encounter Notes, dated 10/16/2023, 10/17/2023, 10/18/2023, and 10/19/2023, the OT Treatment Encounter Notes did not include the application of a right-hand carrot splint. During a review of Resident 110's OT Treatment Encounter Note, dated 10/20/2023, the OT Treatment Encounter Note indicated Resident 110 heavily guarded the right arm but allowed the application of the right-hand carrot splint with a gentle approach and redirection. The OT Encounter Note did not indicate Resident 110 received any pain medication. The OT Encounter Note indicated Resident 110 had the carrot splint applied to the right hand for approximately three hours. The OT Encounter Note indicated Resident 110 had frequent emotional breakdowns and expressed feelings of hopelessness. During a review of Resident 110's OT Treatment Encounter Note, dated 10/24/2023, the OT Treatment Encounter Note indicated Resident 110 had joint tightness in the right hand and received stretching and ROM exercises. The OT Encounter Note indicated the carrot splint was applied to Resident 110's right-hand for two hours. During a review of Resident 110's OT Treatment Encounter Notes, dated 10/25/2023, 10/26/2023, 10/30/2023, 10/31/2023, 11/1/2023, 11/3/2023, 11/6/2023, and 11/7/2023, the OT Treatment Encounter Notes did not include the application of the right-hand carrot splint. During a review of Resident 110's OT Recertification, dated 11/7/2023, the OT Recertification indicated Resident 110 continued to require minimal assistance for self-feeding. Resident 110's OT Recertification included an OT goal for Resident 110 to perform self-feeding tasks with contact guard assistance. The OT Recertification did not include for Resident 110 to use built-up utensils for self-feeding and did not include the use of a right-hand splint. The OT Plan of Treatment for Resident 110 included therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training four times per week for four weeks. During a review of Resident 110's OT Treatment Encounter Notes, dated 11/8/2023, 11/10/2023, 11/13/2023, and 11/14/2023, the OT Treatment Encounter Notes did not include the application of the right-hand carrot splint. During a review of Resident 110's OT Treatment Encounter Note, dated 11/15/2023, the OT Encounter note indicated Resident 110 received PROM to both arms and utilized the left (non-dominant) arm during hygiene and grooming. The OT Treatment Encounter Note did not include the application of the right-hand carrot splint. During a review of Resident 110's OT Treatment Encounter Note, dated 11/16/2023, the OT Treatment Encounter Note, indicated Resident 110 received PROM to both arms. The OT Treatment Encounter Note indicated Resident 110's right hand had skin redness and inflammation in all digits of the right hand, nursing (unknown) was notified, and the right arm was elevated. The OT Treatment Encounter Note did not include the application of the right-hand carrot splint and did not indicate Resident 110 received pain medication. During a review of Resident 110's OT Treatment Encounter Note, dated 11/20/2023, 11/21/2023, 11/22/2023, 11/23/2023, 11/24/2023, 11/28/2023, 11/29/2023, 11/30/2023, and 12/1/2023, the OT Treatment Encounter Note did not include the application of the right-hand carrot splint. During a review of Resident 110's MDS, dated [DATE], the MDS indicated Resident 110 had clear speech, usually expressed ideas, and wants, usually understood verbal content, and improved to intact cognition. The MDS indicated Resident 110 required partial/moderate assistance (helper does less than half the effort) for eating and personal hygiene. The MDS indicated Resident 110 had ROM impairments in one arm and did not have any impairments in either leg. During a review of Resident 110's OT Recertification, dated 12/5/2023, the OT Recertification indicated Resident 110 tolerated a right-hand roll for less than one hour. The OT Recertification indicated a new OT goal for Resident 110 was to tolerate a right-hand roll for four to six hours for contracture management. The OT Plan of Treatment for Resident 110 included orthotic (splint) management, therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training four times per week for four weeks. During a concurrent observation and interview on 1/8/2024 at 2:18 PM in Resident 110's bedroom, Resident 110 described his right hand as a claw which he could not open. During a concurrent observation and interview on 1/9/2024 at 11:20 AM in Resident 110's bedroom, Resident 110 was awake, alert, and moving his left arm actively while lying in bed. Resident 110 was asked to move the right arm, but Resident 110 stated, I do not have a right arm. Resident 110's right hand was in a closed fist position with the forearm positioned in supination (turned with the palm facing upward). Resident 110 slightly lifted the right arm at the shoulder and elbow joints to bend and extend the arm. Resident 110 stated the therapists (in general) did not assist with opening the right hand but placed a splint inside the right hand every one or two days. Resident 110 stated it had been two days since a splint was placed in the right hand and felt that the hand splint was not working. Resident 110 stated, One of my reasons for being here (at the facility) was to build the body, not regress (returning to a less developed state). And I have regressed. During an interview on 1/12/2024 at 8:55 AM in Resident 110's bedroom, Resident 110 stated he was right-hand dominant and initially felt numbness in the right hand. Resident 110 stated the fingertips started to bend, like a claw, and then gradually tightened up into a fist. Resident 110 stated the therapists first started putting a carrot splint in the right hand three days per week. Resident 110 stated the carrot splint did not assist with loosening his fingers, did not fit properly, and did not have a strap to secure it to the right hand. During a concurrent observation and interview on 1/10/2024 at 1:27 PM in Resident 110's bedroom, Resident 110 was awake, alert, lying flat in the bed. Resident 110 had a hand roll splint applied to the palm of the right hand which was secured with a strap across the back of the palm. Resident 110 stated he currently used the left hand to eat meals. Resident 110 became emotional with both eyes tearing up and stated he was feeling miserable, helpless, and hopeless due to his gradual decline in function (activity or purpose natural to or intended for a person). During a concurrent interview and record review on 1/11/2024 at 11:39 AM with the Director of Rehabilitation (DOR) and the ADOR, the DOR and the ADOR reviewed Resident 110's clinical records. The DOR stated Resident 110 received an OT Evaluation on 6/27/2023 (upon readmission), which indicated Resident 110 did not have any contractures and both hands had WFL ROM. The DOR reviewed Resident 110's Rehab - Joint Mobility Screening, dated 7/21/2023, which indicated Resident 110's right hand had a severe impairment. During a concurrent interview and record review on 1/11/2024 at 12:10 PM with the DOR and OT 1, OT 1 stated Resident 110 could actively move both arms, including the right hand, during the OT evaluation on 6/27/2023 (upon readmission). The DOR and OT 1 stated it was a significant change for Resident 110 to progress from WFL in the right hand to severe ROM impairment in the right hand. During an observation and interview on 1/11/2024 at 12:56 PM with the DOR and OT 1 in Resident 110's bedroom, Resident 110 stated, I was always right-handed. Resident 110 stated he felt pain from the right hand all the way up the right arm and stated, I just want to saw it (the right arm) off. Resident 110's right hand was positioned in a fist when OT 1 attempted to passively extend the fingers. Resident 110 moaned and stated he felt a sensation of pain in the right hand. Resident 110 was unable to extend any fingers on the right hand upon OT 1's request. OT 1 stated Resident 110's right hand was tight with severe limitations in all finger joints of the right hand. Resident 110 attempted to bend the right wrist but again moaned with pain. OT 1 stated Resident 110's right wrist ROM was severely limited due to pain. Resident 110 bent and extended the right elbow joint but only slightly lifted the right arm at the shoulder joint. OT 1 attempted to perform PROM to the right shoulder joint but stated Resident 110 could not tolerate additional movement due to pain. OT 1 stated Resident 110 was more alert, awake, and verbal compared to the initial OT evaluation on 6/27/2023 when Resident 110 was nonverbal and dependent. OT 1 stated Resident 110 used to move the right arm but now has right-hand tightness and limited movement due to pain in the right arm. During a review of Resident 110's OT Treatment Encounter Note, dated 1/11/2024 signed by OT 1, the OT Treatment Encounter Note indicated Resident 110 had severe ROM impairment (25% or less of full ROM) in the right shoulder, minimal ROM impairment (approximately 75% of full ROM) in the right elbow, moderate ROM impairment (50% of full ROM) due to pain in the right wrist, and severe ROM impairment to the right hand. During a concurrent interview and record review on 1/11/2024 at 2:42 PM with the DOR, the ADOR, and COTA 1, COTA 1 reviewed the OT Treatment Encounter Note, dated 7/6/2023. COTA 1 stated Resident 110 performed exercises to both arms during the treatment session. COTA 1 stated Resident 110 grabbed onto a dowel rod (thin, straight bar made of wood, plastic, or metal) using both hands and required assistance to lift the dowel to perform the exercises. COTA 1 stated Resident 110's right hand was in a closed position, and COTA 1 may have seen a sign of Resident 110's right hand becoming tight. COTA 1 stated a rolled-up towel was placed in the right hand as a contracture prevention measure. During a concurrent interview and record review on 1/11/2024 at 2:42 PM with the DOR, the ADOR, and OT 1, OT 1 reviewed the OT Treatment Encounter Note, dated 8/1/2023, which indicated Resident 110 received the right-hand carrot splint. OT 1 stated Resident 110's OT Progress Note, dated 8/7/2023, included a new OT goal to wear the hand roll on the right hand for up to four hours. The DOR, the ADOR, and OT 1 reviewed Resident 110's OT Evaluation, dated 9/12/2023, which indicated Resident 110 did not have any contractures but had impaired ROM to the right hand. The DOR, the ADOR, and OT 1 stated Resident 110's right hand was not assessed due to Resident 110's complaint of pain. The DOR, the ADOR, and OT 1 stated Resident 110's goal for the right-hand splint was removed, but OT 1 stated Resident 110's OT goal for the hand splint should have been continued. During an interview on 1/11/2024 at 5:44 PM the OT 1 stated any resident (in general) with ROM impairments should have a splint applied to prevent tightness and contracture development. During a concurrent interview and record review on 1/11/2024 at 6:12 PM with the DOR and the Director of Nursing (DON), the DON reviewed Resident 110's physician's orders and stated Resident 110 had a physician's order for Tylenol as needed for pain management. The DON reviewed Resident 110's MAR and stated pain medication was never administered to Resident 110 during months from 6/2023 to 1/2024. The DOR stated Resident 110's right hand splint was not applied for at least two months between 10/2023 and 12/2023. The DOR stated Resident 110's right hand ROM decline was preventable if the right-hand splint had been applied. During an interview on 1/12/2024 at 9:03 AM with Resident 110's consulting physiatrist ([MD 1], specialist physician who treat patients with injuries or suffer from disabilities that affect physical and cognitive functioning), MD 1 stated Resident 110 was clinically diagnosed (diagnosis made on basis of medical signs and reported symptoms, rather than diagnostic tests) with Dupuytren's contracture (an abnormal thickening of tissues in the palm of the hand) on the right hand. MD 1 stated Resident 110's right hand began to bend at the right ring and little fingers, but MD 1 stated Resident 110 could still use the right thumb, index, and middle fingers to eat. MD 1 stated Dupuytren's was a progressive (disease or physical ailment whose course in most cases is the worsening, growth, or spread of the disease) and had three options for treatment to temporarily slow down the progression. MD 1 stated one treatment included providing ROM and a splint to Resident 110's right hand. During a concurrent interview and record review on 1/12/2024 at 9:56 AM with OT 1, OT 1 reviewed Resident 110's OT Evaluation on 6/27/2023 which included Resident 110's OT goal for hygiene and grooming, OT Recertification on 7/25/2023 which included a goal for self-feeding using built-up utensils, and OT Recertification on 8/22/2023 which included a goal for self-feeding using built-up utensils. OT 1 stated the OT goals were established for Resident 110 to use the right, dominant hand for self-feeding, hygiene, and grooming to maintain function in the right arm. During an interview on 1/12/2024 at 11:04 AM via telephone with OT 2, OT 2 stated Resident 110 was resistant to PROM and touch on the right-hand due to pain during the OT Evaluation on 9/12/2023. OT 2 stated nursing was notified of Resident 110's pain but did not remember if Resident 110 received pain medication. OT 2 stated the right-hand splint was not an appropriate goal during the OT Evaluation since Resident 110 did not allow OT 2 to touch the right hand due to pain. OT 2 did not remember if Resident 110 received any pain medication. OT 2 stated the purpose of a splint was for contracture management and to increase ROM. During an interview on 1/12/2024 at 11:24 AM with the CRT, the CRT stated residents (in general) experiencing pain should receive pain medication prior to any treatment. The CRT stated Resident 110 should have received pain medication prior to the OT assessment on 9/12/2023 to participate in the OT assessment. The CRT stated Resident 110's pain was not a reason to remove the OT goal for the right-hand splint application. During an interview on 1/12/2024 at 1:44 PM via telephone with Resident 110's Responsible Party (RP 1), RP 1 stated Resident 110 was healthy prior to living at the facility. RP 1 stated Resident 110 never ever had any issues with the right hand. RP 1 told the facility staff (unknown) that Resident 110's right hand was not working and asked about treatment options, including surgery, to help improve the right hand. RP 1 stated a carrot splint was placed to the right hand but did not feel it was effective treatment for the fingers and the pain. During a review of the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated Residents will not experience an avoidable reduction in ROM. The P&P also indicated Interventions may incl [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure a resident, who was depended on staff for activities of daily living (ADL), was not subjected to a physical abuse from another resident for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure a certified nursing assistant (CNA 1) monitored the East hallway as assigned to timely intervene to prevent Resident 2 from physically abusing Resident 1 and ensure residents safety. This failure resulted in Resident 2 punching Resident 1 in the head on 8/28/2023 leading to Resident 1 to sustain a left side lateral (on the side) subconjunctival (underneath the clear surface of eyes) hemorrhage (a broken blood vessel that bleeds on the surface of the eye) and a bruise (an injury appearing as an area of discolored skin on the body, caused by a blow or impact causing the underlying blood vessels to burst) around his left eye. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mental health disorder characterized by at least two weeks of persistently sad mood or loss of interest in activities, causing significant impairment in daily life functioning), diabetes mellitus (a group of diseases that affect how the body uses blood sugar to function normally), muscle weakness (a lack of strength in the muscles), and anxiety disorder (uncontrollable excessive fear and worry). During a review of Resident 1's, History and Physical (H&P), dated 5/29/2023, the H&P indicated, Resident 1 had a fluctuating (changing frequently) capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 9/1/2023, the MDS indicated Resident 1 required extensive physical assistance (resident involved in activity, staff provide weight-bearing support) from two or more staff with transfers (from one surface to another), toilet use, personal hygiene, and extensive assistance from one staff for bed mobility (repositioning while in bed), and eating. During a review of Resident 2's General Acute Care Hospital 1 Psychiatric (study of mental illness) Evaluation (GACH 1 PE), dated 7/26/2023, the GACH 1 PE indicated, Resident 2 was admitted to GACH 1 multiple times due to diagnosis of psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and use of methamphetamine (a very addictive drug commonly referred to as meth, a powerful stimulant which is highly addictive that affects the brain and body). The GACH 1 PE indicated, Resident 2 had auditory hallucinations (to hear voices or noises that do not exist in reality) and visual hallucinations (seeing things that are not real, like objects, shapes, people, animals, or lights) that he was unable to describe. The GACH 1 PE indicated, Resident 2 was kicked out of the social security office for making threats and was paranoid (the unreasonable fear or irrational belief that other people are plotting to harm him or her) that people were talking about him. The GACH 1 PE indicated, Resident 2 had been off his medications and had been using methamphetamine. During a review of Resident 2's admission record to the facility, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and causes a break with reality), stimulant (a class of drugs that speed up messages travelling between the brain and body) drug abuse, and major depressive disorder. During a review of Resident 2's H&P, dated 8/4/2023, the H&P indicated, Resident 2 had capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 required extensive physical assistance from one staff with toilet use, personal hygiene, dressing, and limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) from one staff for bed mobility, and transfer. During a review of Resident 2's Initial Psychiatry (a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans) Consult Note (IPCN), dated 8/29/2023, the IPCN indicated, Resident 2 had a sudden outburst of anger on 8/28/2023 and hit Resident 1 (unprovoked- occurring without any identifiable cause or justification) in the face causing injury to Resident 1. The IPCN indicated, Registered Nurse Supervisor (RNS 2) reported Resident 2 was verbally aggressive and acting bizarre. During a review of Resident 1's Change in Condition Evaluation (CICE), dated 8/29/2023, the CICE indicated, Resident 1 was alert and awake and reported to RNS 2 he was hit by his roommate (Resident 2) around 10 p.m. on 8/28/2023. The CICE indicated, there was redness on Resident 1's left eye. During a review of Resident 1's General Acute Care Hospital 2 Emergency Department Provider Notes (GACH 2 EDPN), dated 8/30/2023, the GACH 2 EDPN indicated, that an [AGE] year-old male presented to the emergency department with dizziness, blunt head injury (physical injuries caused by non-penetrating blows from dull objects or surfaces), and periorbital (around the eye area that extends from the upper and lower eyelids to the eyebrows) ecchymosis (a bruise- the blue or purple skin discoloration that occurs as a result of rupture of blood vessels under the skin )status-post (after) allegedly being punched in the face. In the GACH 2 EDPN was documented Resident 1 had a small left-sided lateral subconjunctival hemorrhage. Resident 1 stated that he occasionally has double vision (seeing two images of a single object). The GACH 2 EDPN indicated the recommendation was to follow-up with ophthalmologist (a medical specialty concerned with the study and treatment of disorders of the eye). During a concurrent interview and record review on 9/6/2023, at 5:07 p.m., with CNA 1, the facility's Assignment Shift Report (ASR), dated 8/28/2023 for 3 p.m. to 11:00 p.m. shift was reviewed. The ASR indicated; CNA 1 was assigned to the east hallway from 9:00 p.m. to 10:00 p.m. 8/28/2023. CNA 1 stated, he did not monitor the east hallway from 9:00 p.m. to 10:00 p.m. on 8/28/2023. CNA 1 stated, he had never worked (monitored the residents) in the east hallway, and everybody knew it. CNA 1 stated, he did not notify or complain to the Registered Nurse Supervisor (RNS) or an LVN regarding his assignment and that he would not be monitoring the east hallway. CNA 1 stated, he knows he should follow the assignment, but he did not know why he was assigned to the east hallway that day. CNA 1 stated, CNAs must monitor both hallways by looking and listening to assist residents from emergencies like falls and altercations between the residents and to provide safety. During a concurrent interview and record review on 9/6/2023, at 5:54 p.m., with RNS 1 the facility's ASR, dated 8/28/2023 for the 3:00 p.m. to 11:00 p.m. shift was reviewed. RNS 1 stated, CNA 1 was assigned for the east hallway from 9:00 p.m. to 10:00 p.m. and he should have followed his assigned tasks on the schedule regardless of whether he was familiar with the assignment or not to prevent any incident like the altercation between Resident 1 and Resident 2. RNS 1 stated, hallway monitoring was important to assist residents in a timely manner and keep residents safe from incident like this. During a concurrent observation and interview on 9/6/2023, at 4:45 p.m., with Resident 2, in Resident 2's room in the East hallway, the resident stated, he did not remember the altercation with Resident 1. Resident 2 stated, he was having issues with his previous roommates because they made lots of noises and he was very sensitive with loud noises. Resident 2 refused to talk further regarding the incident that happened on 8/28/2023 and walked away. During a concurrent observation and interview on 9/6/2023, at 4:56 p.m., with Resident 1, in Resident 1's room in the west hallway, Resident 1 was observed to have a bruise around his left eye with redness. Resident 1 stated on 8/28/2023 before 10 p.m. on 8/28/2023 Resident 2 punched twice on his (Resident 1) left side of the face and left eye. Resident 1 stated, Resident 2 walked up to him while he (Resident 1) was watching television and punched him on the left side of his face. Resident 1 stated that he yelled for help several times, because he could not reach his call light, but no one showed up. Resident 1 stated, Resident 2 got mad at him because he yelled for help and punched him again on the left eye. Resident 1 stated, he had to be quiet because he did not want to make Resident 2 upset and get punched again. Resident 1 stated, he was scared and felt helpless. During an interview on 9/6/2023, at 6:05 p.m., the licensed vocation nurse (LVN 3) stated Resident 1 preferred to watch television until 11:00 p.m. while Resident 2 preferred to go to sleep around 9:00 p.m. daily. LVN 3 stated, Resident 2 had a similar issue with noise while he was residing with the previous roommates before he moved to Resident 1's room. LVN 3 stated, Resident 1 was watching television with the volume turned up loud until almost 10:00 p.m., and that could have bothered Resident 2 and triggered the aggression towards Resident 1. During an interview on 9/7/2023, at 11:59 a.m., the Director of Staff Development (DSD) stated, it was not acceptable for CNA 1 not to comply with the facility's policy of performing the tasks he was assigned. DSD stated CNAs were assigned to both east and west hallways to keep residents safe and to attend to the residents' needs right away while other CNAs were assisting other residents. During an interview via phone on 9/8/2023, at 1:19 p.m., the Administrator (ADM) stated monitoring the residents from the hallway was important to keep residents safe and respect their autonomy (allow them their independence and personal space) at the same time. The ADM stated it was an effective method to provide monitoring without intimidating the residents like Resident 2. The ADM stated the second punch from Resident 2 might have been avoidable if staff was monitoring in the east hallway as assigned. During a review of the facility's policy and Procedure (P&P) titled, Resident Rights, undated, the P&P indicated under Policy Interpretation and Implementation:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse and neglect. During a review of the facility's P&P titled, Safety and Supervision of Residents, undated, the P&P indicated under Policy Statement: Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The Policy Interpretation and Implementation Systems Approach to Safety: 1. The facility-oriented and resident -oriented approaches to safety are used together to implement a system approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. Systems Approach to Safety: 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on observation, interview, and record review the facility failed to provide care to one of six sampled resident (Resident 236), who had a negative pressure suction drain (a drainage system that utilizes negative pressure to remove blood or body fluids that may build up in that area) in place, by failing to: 1. Assess Resident 236's wound drain site for signs and symptoms of infection and dislodgement. 2. Obtain a physician's order for wound care and provide care to Resident 236's wound drain site. 3. Secure Resident 236's wound drain tubing to the resident's clothing or his leg to prevent dislodgement. These deficient practices resulted in Resident 236 's wound drain partially dislodged leading to Resident 236 readmition to the general acute care hospital (GACH) for evaluation and treatment due to dislodgement of left knee wound drain. These deficient practices placed Resided 236 at risk for the accumulation of fluid to the wound site, wound non-healing, and infection. Findings: During a review of Resident 236's Admission Record (AR), the AR indicated Resident 236 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including osteoarthritis (wearing down of the protective tissues at the ends of bones) of the left knee and abnormal posture. During a review of Resident 236's History and Physical (H&P) dated 6/16/2023, the H&P indicated Resident 236 did not have the capacity to make decisions. The H&P indicated Resident 236 had an infection of the left knee prosthesis (artificial body part). During an observation on 7/18/2023 at 11:20 a.m., Resident 236 was noted to have wound drain tubing coming out of his left knee with a suture (stitches) secured on Resident 236's left knee. The drainage tubing was observed not secured to his body except for at the suture site. The drainage canister was inside a grey bucket (used for patient care) placed under Resident 236's bed. During an observation and concurrent interview on 7/20/2023 at 12:14 p.m., in Resident 236's room, the resident was observed in bed moving around his legs and the wound drain tubing was observed stuck in the resident's bed frame. The sutures, securing the drainage tubing to Resident 236, was observed tugging (pulling hard) at his skin (the sutures were not in the same spot as observed on 7/18/2023) and there was brownish red fluid draining from the insertion site down Resident 236's left knee. At this time Certified Nursing Assistant (CNA) 7 entered the room to help Resident 236 and untangled the wound drain tubing from the bed frame. Concurrently during an interview CNA 7 confirmed Resident 236's wound drain tubing was stuck in the bed frame so when Resident 236 moved his legs, the wound drain and tubing started pulling out of his leg. During a concurrent observation and interview on 7/20/2023 at 12:16 p.m., in Resident 236's room, Registered Nurse (RN) 1 assessed the wound drain site. RN 1 stated it is fine, the stitch was still attached to the skin. RN 1 stated the wound drainage tubing was not secured to Resident 236's body (by tape) at this time. During an interview on 7/21/2023 at 2:13 p.m., the Director of Nursing (DON), stated all staff providing care to Resident 236 had to assess Resident 236's wound drain tubing to ensure the tubing was not stuck in Resident 236's bed to prevent wound drain from being pulled out of the insertion site and dislodge. The DON stated it was important to have the drainage tubing secured to the resident's body (usually by tape) to prevent the wound drain from accidental dislodgement. The DON stated the dislodged wound drain could result in wound drain not working leading to pain and swelling of the wound. During an observation and concurrent interview on 7/21/2023 at 2:29 p.m., in Resident 236's room, the DON and RN 2 assessed Resident 236's wound drain and insertion site. The DON took out a paper measuring ruler and measured the wound drain tubing from Resident 236's wound drain insertion site on his left knee to the point of the top of the suture (the suture appeared to be stretched). The DON stated the wound drain had been dislodged 4.5 centimeters [(cm) unit of measurement]. The DON stated RN 1 should have informed him and Resident 236's physician the day prior (7/20/2023) the wound drain had been dislodged. The DON stated upon the nurse's assessments they should have realized the wound drain was dislodged. During a review of Resident 236's nurse's progress notes (NPN) dated 7/20/2023, the NPN indicated an assessment was done of Resident 236's left knee and the sutures remained in place. The NPN indicated Resident 236 reported pain at the time of assessment. During a review of Resident 236's NPN dated 7/21/2023, one day after Resident 236's wound drain and tubing observed tugging at his skin, indicated Resident 236's physician (MD 2) was contacted regarding Resident 236's possible partial dislodgement of the wound drain tubing that connects to left knee surgical Hemovac (a type of wound vacuum drain placed under the skin during surgery. This drain removes any blood or other fluids that might build up in this area.). The NPN indicated one suture line was noted to be disconnected from lower line. The NPN indicated a voice mail was left for the orthopedic surgeon [(MD 3) a surgeon who placed the wound drain]. During a review of Resident 236's Discharge Summary Progress Notes (DSPN) dated 7/21/2023, the DSPN indicated Resident 236 was sent to a GACH for evaluation and treatment due to dislodgement of left knee wound drain at 10:52 p.m. on 7/21/2023. During a review of Resident 236's GACH admission H&P dated 7/22/2023 indicated Resident 236 had the history of incision and drainage [(I&D) a surgical procedure to cut the skin over the abscess {a collection of pus in any part of the body}to allow the pus to drain out to let open wound to heal] and placement of drain in the left knee. Resident 236's complained of pain and swelling of the left knee. Resident 236 was sent to the emergency room for evaluation, care and orthopedic (specialty that specialized in bones, and joints) consult for drain removal, possible removal of hardware (replace a missing joint or bone to support a damaged bone) or further debridement (removal of damaged tissue or foreign objects from a wound) of Resident 236's left knee wound. According to a review of [NAME] and [NAME] nursing skills article titled Caring for a Hemovac Drain (wound drain) http://downloads.lww.com the nursing skills article indicated the nurse was to secure the wound drain to the patient gown below the wound and ensure there was no tension on the tubing. The nursing skills article indicated securing the drain prevented injury to the patient by accidental removal of the drain.

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 2), right to be free from physical abuse by Resident 1. Resident 2, who had a history of pacing (walking) and wandering to other Residents rooms, wandered into Resident 1's room and fell asleep in Resident 1's bed. According to License Vocational Nurse (LVN) 2, a Certified Nurse Assistant (CNA) saw Resident 2 sleeping in Resident's 1 bed and took no action. Resident 1 returned to his room and saw Resident 2 on his bed and started hitting Resident 2. As a result, Resident 2 was repeatedly hit in the face by Resident 1. Resident 2 sustained a facial laceration (skin cut) that required Resident 2 to be transferred to the general acute care hospital (GACH) for evaluation and treatment. At the GACH, Resident 2 was diagnosed with blunt head trauma (physical injury caused by non-penetrating blows). Resident 2 received 3 sutures (a row of stitches holding together the edges of a wound) to the left ear and was treated for facial laceration and skin tears. Findings: During a review of Resident 2's Admission Record (AR), indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia unspecified severity with other behavioral disturbance (a progressive and persistent group of thinking and social symptoms, such as thinking and memory impairment, that interfere with daily functioning), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and difficulty walking. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/30/2023, indicated Resident 2 usually understands others and usually able to be understood by staff. The MDS indicated Resident 2 required limited assistance from staff for bed mobility, transfers (from one surface to another), walking in the room and corridor, locomotion on and off unit and toilet use. During a review of Resident 2's Behavioral Notes (BN) dated 7/2/2023 (the date of the altercation with Resident 1), indicated that Resident 2 was referred to Medical Doctor (MD) by staff following his involvement in a resident-to-resident altercation with another male resident, in which he was struck in the head by the other resident (Resident 1). During a review of Resident 2's undated Care Plan (CP) titled bipolar disorder manifested by (MB) behavior of continuous pacing episodes of going to other resident's rooms unattended. The interventions indicated to monitor behavior episodes of continuous pacing every shift (QS). The CP interventions also indicated to monitor, observe and document Resident 2's behavior daily. During a review of Resident 2's undated CP titled Behavior of continuous pacing episodes of going to other resident's room unattended the CP interventions included to monitor episodes of continuous pacing every shift (QS) and document the resident's behaviors daily. During a review of Resident's 2 undated CP titled High wandering risk with a CP goal of minimize behavior of going to other resident's room unattended, the CP intervention indicated 1:1 supervision (person-to-person directly supervising) as indicated, anticipate, and accommodate daily needs, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book. During a review of the Change of Condition form (COC- a report used by health care to indicate a sudden, significant change from a resident's baseline in physical, cognitive or behavior areas) dated 07/02/2023, indicated that Certified Nurse Assistant (name unknown) called Licensed Vocational Nurse (LVN) 1 for assistance with Resident 1 and Resident 2 while fighting. LVN 1 wrote Resident 2 was laying in Resident 1's bed and Resident 1 was aggressively hitting Resident 2. During a review of Resident 1's AR, indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (a serious mood disorder that causes a persistent feeling of sadness and loss of interest, that can interfere with daily life leading to physical and emotional problems), paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) schizophrenia (a brain disorder that causes a break with reality), unspecified mood disorder and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 1's MDS dated [DATE], indicated Resident 1 had the ability to understand and be understood by others. Resident 1 required staff supervision for Activities of Daily Living (ADL's - activities related to personal care) such as bed mobility and eating, limited assistance with getting dressed, transfers, locomotion off unit and toilet use. The MDS indicated Resident 1 used a wheelchair for mobility. During a review of Resident 1's undated CP titled Psychotropic ( a medication that affects the brain by causing changes in mood, awareness, thoughts, feelings and behavior) medications (Haldol) related to(r/t) Paranoid Schizophrenia M/B angry outbursts, interventions indicated that Resident 1 needed to be assisted in avoiding situations that may incite outbursts, monitor and record occurrences for target behavior symptoms and document per facility's protocol. During a review of Resident 1's undated CP titled Physical Restlessness such as threatening behavior of wanting to fight other residents and being aggressive towards his peers indicated interventions such as to assess and anticipate resident's needs like food, thirst, and toileting. The CP goal was for Resident 1 to understand the need to control his behavior. The CP interventions also indicated to analyze key times, places, circumstances, triggers to cause the behaviors, and what de-escalates (the behaviors) and document. During an interview on 7/12/2023 at 11:00 a.m. with LVN 2, LVN 2 stated Resident 2 was witnessed walking towards Resident 1's room and Resident 2 had a habit of sleeping in any available bed. LVN 2 stated the staff that was assigned to monitor residents' movement in the hallways saw Resident 2 sleeping in Resident 1's bed. LVN 2 stated staff should have redirected Resident 2 because he was not aware of his surroundings. LVN 2 stated if staff noted that Resident 2 was in another Resident's room, staff should redirect Resident to his room. During an interview on 7/12/2023 at 11:15 a.m. with LVN 2, LVN 2 stated that the facility has designated staff to monitor the whereabouts of all the residents to make sure all residents are safe from altercations. LVN 2 stated resident to resident altercations are easily preventable, and staff can redirect residents that are wandering into other residents' rooms to prevent altercations. During an interview on 7/12/2023 at 11:30 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated Resident 2 walks in the hallway. If facility staff had closely monitored Resident 2, the altercation with Resident 1 could have been an avoidable incident. Resident 2 was easily redirected. A review of Resident 2's treatment administration record (TAR) dated 7/3/2023, it indicated Resident 1 had a skin tear at the right forearm, scratch mark on the left eyebrow, left cheek laceration and left ear laceration with 3 sutures. During an interview on 7/12/2023 at 11:35 a.m. with LVN 3, LVN 3 stated when he observes or sees other Residents go inside other Residents room, he would try to intervene by redirecting the resident to their own room or assisting the resident to the activity room. LVN 3 stated sometimes he offers snacks to the residents to give the resident something to do. LVN 3 stated to prevent resident to resident altercations from occurring and escalating the staff needs to intervene right away, when the staff identify residents that are confused or do not know where their rooms are located. LVN 3 stated for the incident on 7/2/2023, the staff that was responsible for monitoring the hallways should not have missed Resident 2 going inside Resident 1's room. LVN 3 stated residents that sustain lacerations and require suturing indicate it was a deep cut. LVN 3 stated that Resident 2's injuries could have been prevented by continuous monitoring and intervening right away. During an interview on 7/12/2023 at 12:06 p.m. with the Social Services Director (SSD), the SSD stated this incident that occurred on 7/2/2023 could have been prevented by having the hall monitor redirect Resident 2 and prevent him from wandering into Resident 1's room. Staff should have encouraged Resident 2 to participate in activity groups and get involved in social activity. SSD further added failed supervision can result in resident-to-resident altercations. Residents can wander into other residents' rooms, grab other residents' personal belongings causing agitation, aggravation, irritation with each other, which could lead to injuries. During an interview on 7/12/2023 at 11:50 a.m. with the monitoring staff (MS), the MS stated his duty was to monitor residents' whereabouts, observe, and divert residents' attention. If the resident start to get agitated, the staff should reorient residents and redirect the residents.' The MS further added that his main role as the MS was to supervise, monitor and prevent residents from having altercations and getting injured. The MS stated if a resident was caught entering another resident's room, he would redirect the resident to the resident's room to prevent any incidents. During an interview on 7/12/2023 at 12:10 p.m. with the Director of Nursing (DON), the DON stated all CNAs should be monitoring the hallway activity to prevent unusual interactions between residents, in this case both Resident 1 and Resident 2 were not monitored. The DON stated CNAs and/or LVNs are responsible for monitoring residents and ensure care plan interventions were being implemented. The DON further stated the incident on 7/2/2023, could have been prevented if staff were closely monitoring both residents having identified behaviors. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program (undated), the P&P indicated, implement measures to address factors that may lead to abusive situations for example adequately prepare staff and instruct staff regarding appropriate ways to address interpersonal conflicts. During a review of the facility's P&P titled, Resident Rights, (undated), the P&P indicated, the residents shall be free from abuse, neglect, misappropriation of property (to appropriate wrongly), and exploitation (fact of treating someone unfairly). During a review of the facility's P&P titled, Resident-to-Resident Altercations, (undated), the P&P indicated, facility staff are to monitor residents for aggressive inappropriate behaviors towards other residents, family members, visitors, or to the staff.

Based on observation, interview, and record review, the facility failed to ensure a resident, who was diagnosed with chronic pain and experienced pain due to the presence of several Stage 4 pressure ulcers (wounds that penetrate all layers of skin exposing muscles, tendons, cartilage, and bones caused by prolonged pressure on the skin), received effective pain management for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 received prompt pain relief upon admission to the facility when he complained of severe pain. 2. Ensure Resident 1's physician was promptly notified of Resident 1's continued complaints of severe pain in order to obtain an order for pain medication. 3. Ensure Resident 1's pain level was assessed and reassessed after administration of Tylenol to evaluate the effectiveness of pain medication in relieving pain. 4. Ensure Resident 1's physician was notified in a timely manner when Resident 1's pain management regimen was ineffective. 5. Ensure Resident 1 received appropriate pain relief for severe pain and not Tylenol that was prescribed for mild pain. These deficient practices resulted in Resident 1 experiencing unnecessary severe pain over almost a 40-hour period causing him great distress and discomfort. These deficient practices had the potential for Resident 1's pain to continue to go unrecognized and untreated. Findings: A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy (damage of multiple peripheral nerves which can affect sensation and movement of the body), a Stage 4 pressure ulcers of the left and right heels, a Stage 4 pressure ulcer of the sacrum (area at the bottom of the spine), and chronic pain syndrome (pain that continues for more than three to six months). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 3/16/2023, indicated Resident 1 made independent decisions that were reasonable and consistent. The MDS indicated Resident 1 was totally dependent on staff and required a one-person physical assist for activities of daily living ([ADL] basic skills needed to carry out tasks of everyday life) and a two-person physical assist for bed mobility. A review of Resident 1's Physician Orders (PO) indicated Resident 1 to receive the following medications: 1. Hydromorphone HCL ([Dilaudid]) 4.0 milligrams ([mg] a unit of measurement), IM ([intramuscular] placed into the muscle), every four hours as needed for severe pain, ordered on 6/27/2023. 2. Norco 5/325 mg, one tablet for pain management, one time per day before pressure ulcer treatment, ordered on 6/27/2023. 3. Acetaminophen (Tylenol) oral solution 325 mg/10.15 ml via gastric tube ([GT] a small tube surgically inserted in the stomach for administration of nutrition and medication) every six hours for mild pain, ordered on 6/26/2023. During a concurrent observation and interview on 6/27/2023, at 1 p.m., Resident 1 was lying in bed awake, his arm and legs were noted to be stiff (extended and tense). Resident 1 was observed with facial grimacing (an ugly, twisted expression on a person's face, typically expressing disgust and/or pain) and episodes of twitching of his arms and body. Resident 1 stated he had a lot of pain all over his body and the nurse only gave him Tylenol and it was not helping him. Resident 1 stated he had been waiting for his narcotic pain medication since morning (time unknown) and the nurse told him they were waiting for the pharmacy to dispense his medications, or the doctor had not signed for his medication. Resident 1 stated he did not want to get to the point where he would scream because of the pain. A review of Resident 1's Care Plan (CP), dated 3/11/2023 indicated Resident 1 had chronic pain related to his multiple pressure ulcers and polyneuropathy. The CP's goals indicated Resident 1 would not have discomfort or an interruption in normal activities due to pain. The CP's interventions included to anticipate the needs of Resident 1 for pain relief, respond immediately to any complaint of pain and to notify the physician if interventions were not effective and to monitor, record and report to the nurse, Resident 1's complaints of pain and his request for pain treatment. A review of Resident 1's Medication Administration Record (MAR) for 6/2023 indicated Resident 1 received Tylenol on 6/27/2023 at 10:30 a.m. A review of Resident 1's MAR for 6/2023 indicated Resident 1 received Hydromorphone 4 mg, one tablet on 6/28/2023 at 1:12 a.m., and 4:30 a.m., for pain of 6 out of 10 (severe pain) and at 9 a.m., for pain of 8 out of 10 ([severe pain] based on a numerical pain rating scale from zero to ten, where a zero represents no pain and 10 is the worth pain possible). A review of Resident 1's Pain Observation Assessment (POA) dated 6/26/2023 and timed 10:37 p.m., indicated Resident 1 had a pain level of 9 out of 10. The POA indicated Resident 1 received Dilaudid (Hydromorphone- opioid pain medicine) and Norco ([combination of Hydrocodone with Acetaminophen] narcotic pain medications) for pain. A review of Resident 1's Nursing Progress Notes (NPN) dated 6/26/2023 indicated no additional assessment of Resident 1's pain level following Resident 1's initial pain assessment on 6/26/2023 at 10:37 p.m. A review of Resident 1's NPN dated 6/27/2023 and timed at 2:02 p.m., indicated while Resident 1 was being repositioned in bed the resident complained of pain. A review of Resident 1's NPN dated 6/27/2023 and timed at 3:01 p.m., indicated the Registered Nurse Supervisor (RNS 1) was informed by the Licensed Vocational Nurse (LVN 2) at 2:40 p.m., that Resident 1 was in pain and having muscle spasms. The NPN indicated a review of list of medications from hospital transfer was done and there was no doctor's order to continue Norco and Dilaudid. The NPN indicated Resident 1's physician was notified, and orders were obtained for pain medication. A review of Resident 1's Treatment Administration Record (TAR) dated 6/27/2023 indicated Resident 1's pain was assessed as 7 out of 10 (severe) when the resident had his Stage IV pressure ulcer dressing changed. During an interview on 6/27/2023, at 1:26 p.m., LVN 2 stated Resident 1 was in so much pain he kept asking about his narcotic medication and he (Resident 1) would not allow him (LVN 2) to touch or assess him this morning (time unknown but before 9:30 a.m.). LVN 2 stated, Resident 1 was in pain when LVN 1 (the Treatment Nurse) tried to do Resident 1's a Stage IV pressure ulcer treatment before 10:30 a.m., and Resident 1 was given Tylenol at 10:30 a.m. LVN 2 stated he reassessed Resident 1 for pain at 11:15 a.m. but stated he did not document the pain reassessment after Tylenol was administered. During an interview on 6/27/2023, at 4:38 p.m., RNS 1 stated, Resident 1 would be miserable and his vital signs ([v/s] measurements of the body's most basic functions including temperature, blood pressure, pulse and breathing rate) could be affected if his (Resident 1's) pain was not managed properly because of his chronic pain issues, and Stage IV pressure ulcers on his legs and his sacral area. During an interview on 6/28/2023, at 11:10 a.m., Resident 1 stated, he was experiencing a lot of pain right now, about 10 out of 10 (severe) in his back and he had spasms that went through his stomach and arms along with his Stage IV pressure ulcers and he needs help right now. Resident 1 stated he was given Hydromorphone 4 mg and Tylenol 325 mg at 9 a.m. but these medications were not helping his pain. Resident 1 stated his thoughts were not good right now and the nurses were not giving him anything to stop his pain. During an interview on 6/28/2023, at 11:57 a.m., LVN 4 stated she gave Resident 1 Norco today at 9 a.m. and reassessed him after five minutes and again after 15 minutes and at that time Resident 1 had no pain. LVN 4 stated at 11:15 a.m., Resident 1 was complaining of pain again but did not check his pain level because it was not time to give his pain medication which was ordered every six hours. LVN 4 stated she did not call Resident 1's physician to notify him of Resident 1's continued, unrelieved pain. During an interview on 6/28/2023, at 12:32 p.m., Certified Nursing Assistant (CNA 3) stated, he did not reposition or turn Resident 1 at 10 a.m., today because Resident 1 refused to be repositioned. CNA 3 stated he did not check if Resident 1 was in pain, nor did he notify the charge nurse that Resident 1 refused care. During a phone interview on 6/28/2023, at 3:50 p.m., RNS 3 stated, on 6/26/2023 Resident 1 reported he was experiencing pain that was 9 out of 10. RNS 3 stated she did not call the physician because she thought Resident 1 had an order for Norco and Dilaudid for pain management. RNS 3 stated she did not administer any pain medication to Resident 1 after the resident complained of severe pain because charge nurse and RNS 2 were aware Resident 1 was having pain. RNS 3 stated Resident 1 was always in pain. During a telephone interview on 6/29/2023, at 1:06 p.m., LVN 7 stated, Resident 1 was tired and sleepy when Resident 1 arrived to the facility from the General Acute Care Hospital (GACH) on 6/26/2023 at 7:30 p.m. LVN 7 stated Resident 1 screamed when he was transferred from the gurney (wheeled cot or stretcher used to transport patients) to bed and RNS 3 told her (LVN 7) that Resident 1 had no orders for pain medication. During an interview on 6/29/2023, at 3:35 p.m., RNS 2 stated Resident 1 was not in pain when he arrived from the hospital on 6/26/2023 at approximately 8 p.m. and she was not aware Resident 1 was experiencing a 9 out of 10 pain level during that time. During an interview on 6/30/2023, at 8:20 a.m., LVN 1 stated on 6/27/2023, at 8 a.m., Resident 1 was in pain, but his medication had not arrived from their pharmacy. LVN 1 stated Resident 1 was still in pain when she did his Stage 4 pressure ulcer treatment at approximately 11:30 a.m., despite receiving Tylenol at 10:30 a.m. LVN 1 stated she was not able to finish Resident 1's pressure ulcer treatment because Resident 1 was experiencing pain rated 8 out of 10. LVN 1 stated she reported to LVN 2 and RNS 1 that Resident 1 was experiencing pain. During an interview on 6/30/2023, at 9:10 a.m., CNA 1 stated on 6/27/2023 Resident 1 complained of pain all day. CNA 1 stated, at 7:30 a.m., she notified LVN 2 that Resident 1 was in pain and LVN 2 told her (CNA 1) there was nothing much they could do except to give him Tylenol. CNA 1 stated, she checked Resident 1 at 9:30 a.m., and at 12:30 p.m., and he (Resident 1) complained of pain. CNA 1 stated she reported to LVN 2 again that Resident 1 was in pain and LVN 2 again said, there was nothing she could do because Resident 1's medication was not available During a telephone interview on 6/29/2023 at 5:36 p.m., the Nurse Practitioner (NP) stated, a nurse called her about Resident 1's admission orders on 6/26/2023 at approximately 9:20 p.m. The NP stated, she did not continue Resident 1's medication order for Norco, Fentanyl (a narcotic used to relieve pain) and Dilaudid because she did not know Resident 1 well. The NP stated, she told the nurse to call Resident 1's primary care physician in the morning (6/27/2023) regarding his narcotic pain-relieving medications. The NP stated, she did not receive any more calls from the facility regarding Resident 1's pain. During an interview on 6/30/2023, at 11:25 a.m., RNS 1 stated, on 6/27/2023 she received report from the outgoing night shift RN that Resident 1's narcotic medications that were prescribed from the GACH had been discontinued by the NP. RNS 1 stated on 6/27/2023 after lunch time, LVN 2 told her that Resident 1 was having unrelieved pain. RNS 1 stated she called Resident 1's physician at approximately 2:40 p.m., on 6/27/2023 to obtain an order for continuation of Resident 1's narcotic pain medications. During an interview and concurrent record review with RNS 2 on 6/27/2023 at 5:15 p.m., Resident 1's MAR dated 6/2023 was reviewed. Resident 1's MAR indicated there was no narcotic pain medication administered on 6/26/2023 at 10:37 p.m. RNS 2 stated, Resident 1 was in distress and uncomfortable when his pain was not managed and controlled. RNS 2 stated non-pharmacological interventions (a type of health intervention which is not primarily based on medication) for pain level of 9 out of 10 might not work if Resident 1 was having severe pain. A review of the facility's Policy and Procedure (P/P), titled Pain Assessment and Management, revised 10/2022, indicated residents should be assessed at admission and during ongoing assessments to help identify residents who are experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment. Monitor residents for the presence of pain and the need for further assessment when there is a change of condition or whenever there is a suspicion of new or worsening pain. When opioids are used for pain management, the resident is monitored for medication effectiveness and to contact the prescriber immediately if the resident's pain is not adequately controlled.

Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1), who had a known history of physical aggression toward staff and other residents, did not physically hit Resident 2. The facility failed to: 1. Adequately supervised Resident 1 to prevent Resident 1 from hitting Resident 2 after Resident 1 already had episodes of physical aggression by placing his hands around Resident 3 throat and hit his roommate (Resident 6) in the face causing Resident 6 to bleed from his upper lip. 2. Ensure to follow Resident 1 care plan (CP) titled Potential to demonstrate verbal and or aggressive behaviors with intervention to monitor and document observed behavior to reach the CP goal for Resident 1 not to harm self and others. 3. Ensure the Social Service Worker (SSW) and the Social Services Assistant (SSA 1) informed the Director of Nursing (DON) about Resident 1 wanted to leave the Grove unit (a dedicated locked unit withing the facility), feeling agitated and verbalizing the feeling to hit someone. 4. Administer an Ativan (anti-anxiety medication) as ordered by the physician for Resident 1 agitation and aggression to prevent Resident 1 to hit Resident 2 in the face. 5. Ensure its policy and procedure (P&P) titled, Abuse and neglect clinical protocol (undated), to institute measures to address the needs of residents and minimize the possibility of abuse was followed. 6. Ensure its P&P titled, Safety and Supervision of Residents (undated), was followed to determine Resident 1 frequency and type of supervision due to the resident's aggressive verbal and physical behavior. These failures resulted in Resident 1 striking out by hitting Resident 2 in the face. As a result, Resident 2 sustained a laceration (skin wound) to the left eyebrow lacerations (skin cut), one measuring 3.0 centimeters [(cm) unit of measurement) long and second 5.0 cm. long and required a transfer to the general acute care hospital (GACH) for evaluation and treatment. At the GACH Resident 2 was diagnosed with nondisplaced ocular (bones surrounding the eye) fracture. Findings: During a review of the Resident 1's Face Sheet (Admission record), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE], with diagnosis including drug induced subacute dyskinesia (involuntary body movements), diabetes mellitus (poor blood sugar control), and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and a type of psychosis in which the mind doesn't agree with reality). During a review of Resident 1's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 4/23/2023, the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were intact and the resident required a limited assistance from staff for dressing, transfers, and bed mobility. During a review of Resident 1's Psychosocial Assessment and Social History ([NAME]) form, dated 1/20/2023, the [NAME] form indicated Resident 1 will display angry outburst and get easily agitated, and will strike unprovoked or provoked when over stimulated. During a review of Resident 1's care plan (CP) titled Potential to demonstrate verbal and or aggressive behaviors, dated 1/18/2023, the CP indicated the goal for Resident 1 was not to harm self or others through the review date. The CP interventions included to monitor, and document observed and attempted interventions in behavior log. During a review of the Resident 1's CP, dated 1/20/2023, the CP indicated that Resident 1 gets easily agitated. The CP interventions included to administer Lorazepam ([Ativan, an anti-anxiety medication]) intramuscular [(IM) into the muscle] as ordered by the physician, monitor behaviors daily and review increasing behaviors requiring re-evaluation. During a record review of a physician's note, dated 1/24/2023, the note indicated Resident 1 hit his roommate (Resident 6) in the face and caused to bleed from his upper lip. Physician note indicated Resident 1 verbalized he hit his roommate because his roommate (Resident 6) did not flush the toilet two times. The physician note indicated Resident 1 was ordered to transfer to GACH emergency room for evaluation and treatment and administer stat Benadryl (fast acting anti-anxiety) 50 mg one dose IM, Ativan 1 mg IM stat (immediately), and Haldol (anti-psychotic) 5 mg IM. During a review of Resident 1's CP, dated 2/22/2023, and titled History of Physical aggression towards another resident related to diagnosis of paranoid schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), and psychosis (mental disorder characterized by a disconnection from reality.), the CP indicated Resident 1 was identified as physical and verbally aggressive towards others. During a review of Resident 1's Change of Condition (COC) note, dated 5/14/2023, the COC indicated Resident 1 was verbally aggressive, yelling, and screaming at peers and staff. During a review of Resident 1's COC note, dated 5/20/2023, the COC indicated Resident 1 allegedly placed his hands around the throat of Resident 3. The COC indicated Resident 1 was transferred to the Grove Unit (locked unit in the facility) the same day after this incident. During a review of the Social Services progress notes (SSPN), dated 5/22/2023 and 5/23/23, the SSPN indicated Resident 1 had spent three days in his new room (after he was moved), and did not like being at the Grove unit. The SSPN indicated Resident 1 felt that peers were intrusive and he more likely to strike someone, or someone will strike him. Resident 1 expressed frustration about his new living place to social service worker (SSW) regarding his peers. Resident 1 wanted to be removed from the Grove unit to avoid any altercations with peers. SSW encouraged 1 to remain calm and refrain from any aggressive behavior. The SSPN indicated there was no documentation about SSW communicated to nurses or Resident 1's physician about how Resident 1 felt staying at the Grove unit. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including a major depressive disorder, schizophrenia, unspecified mood disorder and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills were intact, and the resident required staff supervision for dressing, transfers, and bed mobility. The MDS indicated Resident 2 used a walker and wheelchair for mobility. During a review of Resident 1's COC note, dated 6/5/2023, and timed at 5:20 p.m., the COC indicated Resident 1 was agitated, yelling, screaming, and cursing, and was about to hit at staff but did not. The COC indicated no physical contact was noted during the 7a.m. to 3p.m. shift. COC indicated there were no interventions in place to address Resident 1 agitation. During a review of Resident 1's PO, dated 6/5/2023, the PO indicated Resident 1 had an order for Lorazepam 0.5 milliliters [(ml) unit of liquid measurement] IM every six hours as needed (PRN) for agitation manifested by aggressive behavior for 14 days. During a review of Resident 2's COC note, dated 6/5/2023, Resident 2 sustained two left eyebrow lacerations, one measuring 3.0 cm long and second 5.0 cm long. The COC indicated that Resident 2 was hit by Resident 1 and initial treatment was provided. Resident 2 was then transferred to the GACH for further treatment. During a review of Resident 2's PO dated 6/5/2023, the PO indicated Resident 2 was transferred to the GACH via 911 for treatment and evaluation. During a review of Resident 1's PO, dated 6/5/2023, the PO indicated to transfer Resident 1 to the GACH for psychiatric (medical doctor who studies, diagnoses and threats mental illnesses) evaluation and treatment related to aggressive behavior. During a review of Resident 2's a Computed Tomography ([CT] a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) report dated 6/6/2023 and timed at 1:14 a.m., the CT scan report indicated Resident 2 sustained a comminuted fracture (broken bone in at least two places) of the supraorbital rim (located above the eye socket) and the left frontal bone (flat bone of the skull located in the forehead). During an interview with the Social Services Assistant (SSA 1), on 6/7/23, at 10:35 a.m., SSA 1 stated that Resident 1 was transferred to the lock unit after an alleged altercation with Resident 2. SSA 1 stated that he recalls Resident 1 stated he felt like he was going to strike a resident if he (Resident 1) stayed in the room he was assigned on the Grove unit. SSA 1 stated Resident 1 verbalized he wanted to get out of Grove unit daily. SSA 1 stated that he (SSA 1) told the charge nurse and the other social workers this information. SSA 1 stated that he (SSAA 1) should have reported to the Director of Nursing (DON). During an interview with the DON, on 6/7/2023, at 11:11a.m., the DON stated Resident 1 had a known history of mood swings and aggressive behavior. The DON confirmed Resident 1 allegedly place his hands around the neck of Resident 3 in mid- May 2023, and had another incident of displaying aggression with another resident (Resident 6) in January of 2023. The DON stated if he (DON) was made aware about the SSA 1's notes regarding Resident 1's not wanting to be in the Grove unit and feelings of hitting another resident, he would have held an Interdisciplinary Team (IDT) meeting and implemented Certified Nurse Assistant (CNA) 1:1 (intervention aimed to keep patients safe through direct observation by staff) behavior monitoring. The DON stated that SSA 1 should have made him (DON) aware during the daily staff huddles and group texts. During a phone interview with CNA 1, on 6/7/2023 at 12:41p.m., CNA 1 stated that he was called twice during the morning shift (7 a.m. to 3 p.m.) to assist Licensed Vocational Nurse 1 (LVN 1) with the administration of medications to Resident 1. CNA 1 stated Resident 1 was being aggressive and did not want to take his medications. CNA 1 confirmed Resident 1 was agitated and verbally aggressive on and off throughout the morning shift, starting at 10 a.m. During an interview with LVN 3, on 6/7/2023, at 2:52 p.m., LVN 3 stated that she was working the 3 p.m., to 11 p.m. shift as the desk nurse on 6/5/2023. LVN 3 sated she was endorsed that Resident 1 was being verbally aggressive and tried hitting staff on the previous shift (7 a.m. to 3 p.m.). LVN 3 stated she was aware of Ativan order prn but Resident 1 was calm while she (LVN 3) made her rounds at the shift change. LVN 3 stated Resident 1 had another outburst of aggression around 5 p.m., but Ativan was not given. LVN 3 stated Resident 1 was aggressive toward staff, but not his roommates. LVN 3 stated Resident 1 should have been put on 1:1 monitoring and the incident with Resident 2 probably would have not happened. During an interview with the Social Worker (SW 1), on 6/8/2023, at 9:34 a.m., SW 1 stated Resident 1 was loud, rude and disrespectful and went off on me one time. SW 1 stated if a resident had verbalized a wish to transfer out of a certain unit and verbalized a feeling to hit someone, we would get the team together, do an interdisciplinary team ([IDT]a group of professionals working together toward a common goal) meeting, and would notify the DON as it was a safety issue. During a concurrent interview and review of Resident 1's the licensed nurses progress notes (NPN) on 6/8/2023, at 3:40 p.m., with LVN 1, the NPN dated 6/5/2023 indicated Resident 1 was having aggressive behavior trying to attack staff with no physical contact. LVN 1 confirmed that she documented in NPN and had witnessed Resident 1's episode of aggression at 5 p.m. on 6/5/2023. LVN 1 stated she did not administer Ativan to Resident 1 for agitation as ordered. LVN 1 stated that LVN 2 had the keys to access the medication and she had only documented the incident to help out. LVN 2 stated that she endorsed the keys to LVN 1 and LVN 3 before leaving. During an interview with the DON on 6/8/2023 at 4:07 p.m., the DON stated Resident 1 should have been closely monitored given Resident 1's history of aggression. The DON stated that everyone in the facility is responsible for the safety of the residents. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents (undated), the P&P indicated the type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The P&P also indicated the type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. During a review of the facility's P&P titled, Abuse and neglect clinical protocol (undated), the P&P indicated, the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. During a review of the facility's P&P titled, Resident Rights, (undated), the P&P indicated, the residents shall be free from abuse, neglect, misappropriation of property, and exploitation. During a review of the facility's P&P titled, Resident-to-resident altercations, (undated), the P&P indicated, facility staff are to monitor residents for aggressive inappropriate behaviors towards other residents, family members, visitors, or to the staff. During a record review of the facility's Job description (JD): Social Services Assistant (SSA), dated 1/2019, the JD indicated the SSA is to assist with providing medically related social services so that the highest practicable physical, mental, and psychosocial well-being of each resident is attained or maintained. The job description also indicated the SSA is to meet with department personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or the improvement of services.

Based on interview and record review, the facility failed to ensure the resident was free of physical abuse for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) did not physically assault Resident 1, by hitting him in the eye. 2. Ensure the facility's staff adhere to its policy and procedure (P/P) titled, Abuse Prohibition/Prevention Policy and Procedure, which indicated each resident has the right to be free from abuse and mistreatment. These failures resulted in Resident 1's rights being denied, and the resident being hit by CNA 1 in the left eye and sustained discoloration to the left eye. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including paranoid (obsessively suspicious) schizophrenia (a mental disorder characterized by abnormal social behavior and failure to understand what is real) and post-traumatic stress disorder ([PTSD] a mental health condition triggered by a terrifying event - either experiencing it or witnessing it). During a review of Resident 1's history and physical (H/P), dated 2/25/2021, the H/P indicated Resident 1 was diagnosed as having PTSD, schizophrenia, and was confused. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/3/2021, the MDS indicated Resident 1 usually had the ability to understand and be understood and had moderately impaired cognitive (thought process) skills for daily decision-making. According to the MDS, Resident 1 had no behavioral problems. During a review of Resident 1's Order Summary Report (active attending physician's orders) dated 3/31/2021, the report indicated there was a physician order dated 12/6/2020, for Haldol Decanoate (an antipsychotic used for long-term treatment of mental disorders) solution 50 milligrams ([mg] unit of measurement) per milliliter ([ml] unit of measurement) injection to be given 1.5 ml once every 28 days, related to the resident's paranoid schizophrenia behavior manifestation by aggression-hitting behavior. During a review of Resident 1's Medication Administration Record (MAR) for the month of 3/2021, the licensed nurse (unidentified) documented Resident 1 received Haldol Decanoate Solution 50 mg injection on 3/9/2021 at 9 a.m. During a review of Resident 1's Nursing Progress Note (NPN) dated 3/28/2021 and timed at 6 a.m., the NPN indicated Resident 1 complained a male CNA (CNA 1) hit him in the face two days prior (3/26/2021). According to the NPN, an assessment Resident 1 was noted to have a fading black discoloration underneath the left eye which measured 3.5 X 2.0 centimeters ([cm] unit of measurement) and the resident denied pain. On 3/28/2021, at 6:40 a.m., an unidentified licensed nurse documented Resident 1 stated CNA 1 hit him in the face because the resident was cursing at CNA 1. The NPN indicated the abuse incident was reported to the local police department, California Department of Health (CDPH) and Ombudsman (resident advocate). The NPN indicated CNA 1 was interviewed about the abuse and he stated, That Friday morning around 10 a.m., I went into Resident 1's room and was caring for the resident's roommate, Resident 2. A janitor came in the room and Resident 1 started cursing (using expletive/obscenity/profanity words) at the janitor. I (CNA 1) told him to stop, and he (Resident 1) would not stop and then the resident started to curse at me. CNA 1 stated he held Resident 1's chin and closed the Resident 1's mouth, trying to get him shut up. CNA 1 stated he may have held the resident down too hard and caused the bruising. The NPN indicated CNA 1 was suspended immediately and sent home. During a review of the CNA 1's documentation report for the month of 3/2021, CNA 1 was Resident 1's primary CNA on the following days 3/1/2021, 3/3/2021, 3/4/2021, 3/7-10/2021, 3/13/2021, 3/14/2021, 3/16/2021, 3/19/2021, 3/21/2021, and 3/25-27/2021. During a review of Resident 1's NPN dated 3/28/2021 and timed a 9:15 p.m., the NPN indicated the police came to the facility to speak to Resident 1 about the abuse incident.When the police officer (PO 1) saw Resident 1's eye, PO 1 called 911 (emergency services) for the resident to be evaluated. According to the NPN, the paramedics arrived, evaluated Resident 1, and stated the resident needed no further care from them. During a review of Resident 1's Change in Condition Evaluation (COC), dated 3/28/2021, the COC indicated there was a fading discoloration on Resident's 1 left eye measuring 3.0 X 2.0 c.m. with skin intact and no swelling. The COC indicated the resident's skin was intact and the resident was not complaining of pain at that time. The COC indicated Resident 1 stated CNA 1 hit him in the face because he (Resident 1) cursed at CNA 1 and he had a black eye after CNA 1 hit him. The COC summary indicated CNA 1 was suspended immediately pending investigation. During a review of CNA 1's Notice of Employee Separation (NES) dated 4/1/2021, the NES indicated the hire date was 1/30/2019 and the termination date was 4/1/2021. The NES, under Involuntary Termination, indicated CNA 1 was terminated for violating company policies. During an interview with Resident 1 on 5/13/2021 at 1:38 p.m., Resident 1 stated, The case was closed, and a police officer (PO 1) came to the facility and interviewed me a month ago about the CNA hitting me. I do not want to continue to drag this out after being hit by the CNA, I just want to get out of here. During an interview with Registered Nurse 1 (RN) 1 on 1/18/2023 at 4:10 p.m., RN 1 stated CNA 1 admitted to holding Resident 1's mouth close because the resident was cursing at him. RN 1 stated she sent CNA 1 home immediately (3/26/2021) and reported the incident to the director of nurses (DON). During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/6/2023 at 1:30 p.m., LVN 1 stated she recalled the incident between Resident 1 and CNA 1. LVN 1 stated she could not recall the CNA's name and CNA 1 no longer worked at the facility. During an interview with the social service designee (SSD) on 2/7/2023 at 11 a.m., the SSD stated she remembered the incident, however, she was not able to recall CNA 1's name. There was no investigation report available for review. During an interview with the director of staff development (DSD) on 2/14/2023 at 10 a.m., CNA 1's employment file was requested and the DSD stated she would call back once located. On 2/15/2023 at 10:40 a.m., the DSD stated CNA 1 employment file could not be located in the facility. CNA 1 was not available for interview due to the lack of contact information and employee file from the DSD. During a review of the facility's policy and procedure (P/P), with a revised date of 3/2018 and titled, Abuse Prohibition/Prevention Policy and Procedure, the P/P indicated each resident has the right to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment.

Based on interview and record review, the facility failed to ensure a resident, who had a wandering (a person that roams around and becomes lost or confused about their location) behavior and had a history of aggressive behavior (hitting and yelling at others) did not physically abuse another resident for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) had knowledge of Resident 1's wandering behavior and monitor Resident 1's whereabouts on the day of the incident (3/2/2023). 2. Ensure to have an assigned CNA to monitor the hallway on the day of the incident (3/2/2023) to prevent Resident 1 from wandering into Resident 2's room and hitting Resident 2 in the forehead with a bottle of lotion. This deficient practice resulted in Resident 1 wandering into Resident 2 room, throwing a lotion bottle at Resident 2, hitting Resident 2 face, and causing the resident pain. Resident 2 sustained a bruise (an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) on her forehead. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 1's history and physical (H/P), dated 12/18/2022, the H/P indicated Resident 1 did not have the ability to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/23/2022, the MDS indicated that Resident 1 had unclear speech and sometimes was able to understand and be understood by others. According to the MDS, Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing [body weight] support) with a one-person physical assist during toilet use (how resident uses toilet room, commode, bedpan, transfers on and off toilet) and transferring. The MDS indicated Resident 1 had hallucinations (perceptual experiences in the absence of real external stimuli) and delusions (misconceptions of beliefs that are firmly held, contrary to reality). According to the MDS Resident 1 used a wheelchair (w/c) as a mobility device. During a review of Resident 1's care plan (CP), untitled, initiated on 8/5/2015 and revised on 7/7/2022, the CP indicated Resident 1 was wandering into other residents rooms and was at risk for injury to self or others secondary to impaired mental health condition. The CP indicated the goal for Resident 1 was not to have injuries to self and not to cause injuries to others weekly. The CP interventions included staff to monitor Resident 1's whereabouts and remove Resident 1 from any source of agitation and redirect the resident. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (diseases that result in too much sugar in the blood) and muscle weakness and anxiety disorder. During a review of Resident 2's History and Physical (H/P), dated 2/3/2023, the H/P indicated Resident 2 did not have the ability to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderately impaired cognitive skill (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision-making and required extensive assistance with one-person physical assistance for toilet use and transferring. During a review of Resident 2's Change of Condition (COC) form, dated 3/2/2023, the COC indicated Resident 2 was hit on the left forehead by Resident 1 with a bottle. During a review of Resident 2's Interdisciplinary (IDT) Progress Notes (PN), dated 3/3/2023, the IDT PN indicated that an incident of physical aggression between Resident 1 and Resident 2 occurred on 3/2/2023 at 9:30 am. The IDT PN indicated the Registered Nurse received a report from a Charge Nurse indicating Resident 1 threw a bottle at Resident 2 hitting Resident 2 on the left side of the forehead. Resident 2 was assessed and noted to have mild bluish discoloration appropriately 3.0 by 2.0 centimeters [(cm)-unit of measurement of length] to the left side of her forehead. The IDT PN indicated Resident 2 was oriented to name, place, and time. During an interview on 3/14/2023 at 11:00 a.m., with CNA 1, CNA 1 stated on 3/2/2023 at 9:30 a.m., he was assigned to Resident 1, however, he was not aware of Resident 1's whereabouts. CNA 1 stated he was in another resident's room at the time of the incident. CNA 1 acknowledged there should be an assigned CNA responsible for monitoring the hallway to prevent accidents, fights and to redirect residents from wandering into other residents' rooms. CNA 1 stated he did not know who was assigned to be the hallway monitor during the time of the incident. CNA 1 stated the CNA assigned to monitor the hallway observes the residents with wandering behavior to ensure they do not wander into other residents' rooms. The CNA assigned to monitor the hallway must always keep an eye on the hallway traffic. During an interview on 3/14/2023 at 11:10 a.m., with Registered Nurse Supervisor (RNS 1), RNS 1 stated Resident 1 had a history of wandering into other residents' rooms. RNS 1 stated the facility assigned CNA to monitor the hallway in hourly intervals to ensure residents do not fall in the hallways, ensure residents do not wander into other residents' rooms and to prevent any accidents or fights between residents. RNS 1 stated when a CNA is assigned to monitor hallway, the CAN's job is to be at the end of the hallway and monitor the residents that are in the hallway. RNS 1 stated the assigned CNA must always maintain line of sight on the residents in the hallway. RNS 1 stated if a CNA, who is assigned to monitor the hallway is called to help another resident, the CNA must have another staff member take over monitoring the hallway. During an interview on 3/17/2023 at 4 p.m. with the Director of Nursing (DON), the DON stated the facility must provide appropriate supervision to meet the needs of the residents. The DON stated Resident 1 had a known history of wandering into other residents' rooms and being aggressive. The DON stated, the facility had a system in place to ensure there was a hallway monitoring to supervise residents in the hallway. The DON stated the staff assignment which included the hallway assignment was not created for 3/2/2023 and more than likely there was no CNA directly assigned to watch the hallway which would have prevented Resident 1 from entering Resident 2's room. During a phone interview on 3/20/2023 at 4 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 3/2/2023 at approximately 9:35 a.m., she heard Resident 2 yelling for help in her room. LVN 1 stated as she entered Resident 2's room and met Resident 1 exiting from Resident 2's room in his wheelchair. LVN 1 stated Resident 2 informed her that Resident 1 hit her on the forehead with a bottle. LVN 1 stated she saw a bottle on the floor next to Resident 2's bed but did not witness the incident that Resident 2 described. LVN 1 stated Resident 1 should not have been in Resident 2's room. LVN 1 stated Resident 1 was known wanderer and should have been redirected from entering Resident 2's room. During a review of the facility's policy and procedure (P/P) titled, Safety and Supervision of Residents, revised 7/2017, the P/P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility -wide policies. The P/P indicated the facility has an individualized, resident- centered approach to safety, the IDT team shall analyze information obtained from assessment and observations to identify any specific accident hazard or risks for individual residents, implement interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff assigning responsibility for carrying out interventions, ensuring interventions are implemented and documenting interventions.

Based on observation, interview and record review, the facility failed to provide supervision and follow the facility ' s policy and procedure titled, Safety and Supervision of Residents, to ensure one of three sampled residents (Resident 1) did not elope (leaving a secured institution without notice or permission) from a locked unit in the facility. The policy indicated the care team would determine the individuals ' assessed needs for the type and frequency of the resident ' s supervision. Resident 1 was admitted to the facility on [DATE] at 11:30 am., to a locked unit and discovered missing on 3/4/2023 at approximately 10: 45 pm. Resident 1 was in the facility for approximately 11 hours. According to licensed vocational nurse (LVN) 2, all new admissions are closely visually monitored for 72 hours to screen the residents ' behavior. As a result, Resident 1 eloped from the facility on 3/4/2023 and remains missing. This deficient practice resulted in Resident 1 leaving the facility with the potential of being exposed to severe environmental conditions including excessive cold, possible motor vehicle accident, medical complications including malnutrition (health problems that may arise due to lack of nutrients [substances found in food necessary for the body to function normally]), dehydration (abnormally low fluid levels in the body), stroke (injury to brain tissue caused by hypertension [abnormally high blood pressure] ) due to missing routine medications including high blood pressure medication, and mood stabilizer medication. On 3/8/2023 at 4:22 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was identified and called in the presence of Administrator (ADMIN) and the Director of Nursing (DON) due to the facility's failure to have a system in place to prevent a new admission, Resident 1, that was on 72 hour close monitoring, from eloping from the facility ' s locked unit. On 3/9/2023 at 3:56 p.m., the facility submitted an acceptable IJ removal plan (IJRP, interventions to immediately correct the deficient practices). After onsite verification of IJRP implementation, through observation, interviews, and record reviews, the IJ was removed on 3/9/2023 at 4:23 p.m., in the presence of the DON. The IJPR included the following immediate actions: a. In-Service of facility staff on 3/7/23 regarding: - Staff to be more vigilant when opening exit doors to ensure no residents within immediate surroundings, checking the door behind to ensure it is locked/engaged, and any unfamiliar individual not wearing uniforms/name badge will not be allowed to go through exit doors without verification or supervision. - Staff to wear name badges appropriately and should be visible while at workplace. - Licensed nurses will obtain a photograph of every new admission facility-wide in the absence of Activities staff. Activities staff will download pictures of new admissions the next business day. - Residents identified with moderate risk for elopement will be monitored visually, every 2 hours, through a Behavior Mapping Tool in Point of Care (electronic documenting system), under Certified Nurse Assistant (CNA) -Task. CNAs are to report to charge nurses in any new onset or increase episode of wandering behavior. - High risk residents will be monitored hourly utilizing Behavior Mapping Tool. CNAs are to report to charge nurses in any new onset or increased episodes of wandering behavior. - Each CNA is assigned to 9-10 residents all throughout the facility to care and monitor to ensure residents are supervised and kept safe. The director of nursing/ director of staff development will review staffing projections (staffing needs assessments) and adjustments will be made as appropriate for high demand/high acuity residents. b. All 4 identified exit doors throughout the facility will be monitored hourly for functionality to ensure exit doors are locking/engaging properly. These exit doors are entrances/exits that employees use as passageways to leave/enter the facility or move between units, namely: Palm Court and Palm Grove (locked unit). These four exit doors are identified as follows: Palm Court Main lobby, Palm Court after-hours entrance/exit door (behind Administrator ' s office), Palm Court East (passage going to Palm Grove/locked unit), and Palm Grove entrance/exit. c. Current staff including those from the registry, administration, dietary, housekeeping, rehab, etc. will be in-serviced (on items a. and b. above) by the director of nursing or designee, and no staff will be allowed to report to work assignments until in-service is completed. Facility will complete 100% staff in-service by 3/10/2023. Staff on per diem status, unavailable or on vacation will receive in-service training through the phone if able, until such will return to work then a face-to-face training will be done. d. During new hire orientation and annual performance evaluation, staff will receive training on facility ' s wandering/elopement policy and procedures, resident ' s safety, monitoring of resident ' s whereabouts and providing adequate supervision. The administrator will randomly review 5 employees' files monthly to audit evidence of training during the next 3 months. e. For pre-admission screening, DON will ensure elopement risk and residents with history of suicidal ideations ' documents are reviewed before a new admission is accepted. A plan will already be in place, discussed with the Interdisciplinary Team (IDT- each resident ' s health care team) if necessary, and communicated to nursing staff (including registry staff) before the resident is transferred to the facility. Any referral for new admission/readmission with active suicidal ideation will be denied placement until a clearance from psychiatrist is obtained. f. Any in-house resident experiencing suicidal ideation will be immediately placed on 1:1 monitoring until transfer to a more appropriate setting is done. g. The Environmental supervisor will check all windows, exit doors, emergency exits, perimeter fence and gates for proper functioning daily. Administrator will review log weekly for the next 3 months. h. Department heads will conduct exit door staff compliance checks to at least 10 random staff members weekly for 3 months to ensure staff entering or exiting locked doors are keeping residents safe and preventing them from eloping - any issues will be communicated to administrator or director of nursing for immediate resolution for the next 3 months. Findings: During a review of Resident 1 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility ' s locked unit on 3/4/2023 with diagnoses including paranoid schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real), hypertension, anxiety (Feeling nervous, restless or tense, having a sense of impending danger, or panic) and insomnia (sleep disorder that makes it difficult to sleep). During a review of Resident 1 ' s General Acute Care Hospital (GACH - where Resident 1 was transferred) Psychiatric Evaluation (PE) dated 2/7/2023, the PE indicated that Resident 1 had been expressing feelings of helplessness, hopelessness, worthlessness with suicidal thoughts with intent to walk in traffic or overdose. During a review of Resident 1 ' s elopement risk assessment (ERA) dated 3/04/2023, the ERA indicated Resident 1 scored 7 (score of 7 indicated the resident was a moderate risk for elopement). During a review of Resident 1's physician ' s order dated 3/4/2023, the physician ' s order indicated lisinopril (blood pressure medication) 10 milligrams ([mg] unit of measurement), 1 tablet by mouth one time day, divalproex sodium (mood stabilizer medication) 500mg to be given 3 times a day and risperidone (medication for schizoaffective [symptoms including the minds break from realty, and severe mood swings] disorder ) 2mg to be given twice a day manifested by paranoid schizophrenia. During a review of Resident 1 ' s Care plan (C/P) dated 3/4/2023. The C/P indicated Resident 1 was at risk for wandering/elopement with a score of 7- moderate risk. Goals set for Resident 1 indicated Resident 1 will not have episode of seeking exits, resident ' s safety will be maintained through the review date (next assessment date), 3/6/2023 and that the resident will not leave the facility unattended through the review date. Interventions included: clearly identify Residents ' room and bathroom to avoid going to other resident ' s bathroom, engage resident in purposeful activity to keep self-busy and monitor whereabouts closely. During a review of Resident 1 ' s Nursing Progress Note (NPN) dated 3/5/2023 at 2:39 a.m., the NPN indicated that at 10:45 p.m. (on 3/4/2023), Resident 1 was reported missing to the local sheriff department. During an interview on 3/7/2023 at 9:44 a.m., Certified Nursing Assistant (CNA) 3 stated CNAs are assigned an area (each) to monitor, the three areas are the east and west hallways and the patio (areas in the locked units with exits). CNA 3 stated monitoring was done due to the unpredictable behavior (exit seeking, altercations, or accidents) of the residents in the locked unit. During an interview on 3/7/2023 at 10:25 a.m., with the Maintenance Supervisor (MS), the MS stated the exit doors require at least 300-400 pounds of pressure to be opened and that they can be opened in event of emergency. The MS states that all the exit doors require a key to be opened and the only people that have keys are staff members. During an interview on 3/7/2023 at 12:21 p.m., with LVN 2, LVN 2 stated new admissions need to be closely monitored for 72 hours to screen the residents ' behavior and the result of monitoring needed to be documented. LVN 2 stated the purpose of monitoring new admissions was because residents in this (locked) unit can be aggressive and show exit seeking behavior because the residents are in a new and unfamiliar environment. During an interview on 3/7/2023 at 4:06 p.m., with Registered Nurse (RN) 2, RN 2 stated that the locked unit was fully staffed, a CNA was stationed in each hallway and patio, if a resident was able to leave the unit, staff should have been able to see the resident leave. RN 2 also stated there was no picture of Resident 1 in his medical record, and it would have helped identify Resident 1. During a phone interview on 3/7/2023 at 4:37 p.m., with LVN 1, LVN 1 stated Resident 1 was last seen around 8:30 p.m. on 3/4/2023, which was the last smoke break for the evening. LVN 1 stated that Resident 1 ' s elopement put him at risk for getting hurt, hit by a vehicle or can get sick from exposure to extreme weather. During an interview on 3/8/2023 at 9:30 a.m., with the admissions coordinator (AC), the AC stated the admissions staff and the nursing staff collaborated on which unit to place a new resident in. Factors in making that decision are age, medical history, and any other details that nursing receives during report. Resident 1 was placed in the locked unit due to him being young and the resident ' s suicidal history. During a concurrent observation and interview on 3/8/2023 at 1:17 p.m., CNA 4 was observed monitoring the exit door of the locked unit, CNA 4 stated someone should be watching the hallways and exit doors and we (CNAs) cannot leave the area unattended. CNA 4 stated if there was a need to leave an exit unattended, then the charge nurse needs to be notified or one of our colleagues (facility ' s staff). During a concurrent interview and record review on 3/8/2023 at 2:20 p.m., with the DON, the DON stated a staff member should be monitoring the patio, and the east and west hallways at all times. The document titled Nursing Staffing Assignment and Sign In dated for 3/4/2023 indicated that seven CNAs were on shift when Resident 1 eloped from the facility. The DON stated there was more than enough staff to monitor the unit and the staff weren ' t properly monitoring the exits. The DON stated that the safety of all residents is the responsibility of all staff members. According to the Accuweather forecast report for Artesia area from 03/04/2023 to 03/09/2023 https://www.accuweather.com/en/us/artesia/90701/march-weather/332029, the temperature was in the high 50 ' s degree Fahrenheit ( F, referring to temperature) to low 60 ' s F during the day, and 30 ' s F to mid 40 ' s F during the night. During a review of the facility ' s policy and procedure (P/P) titled Safety and Supervision of Residents revised July 2017, the P/P indicated that resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents ' assessed needs. The P/P also indicated the frequency and type of supervision varied per the needs of each resident. During a review of the facility ' s document titled Standard of Certified Nursing Assistant (CNA) Practice, revised 11/2012, the document indicated The CNA is responsible to each resident in the facility and should - together with all staff- attempt to determine and meet resident needs, as possible, according to applicable capabilities and regulations.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Seventeen medication errors out of 44 total opportunities contributed to an overall medication error rate of 38.64 % affecting three of six residents observed for medication administration (Residents 51, 200, and 257.) The medication errors were as follows: 1. Omitted or late administration of metoprolol succinate (a medication used to treat high blood pressure) 50 milligrams (mg - a unit of measure for mass) for Resident 51 2. Omitted or late administration of tamsulosin 0.4 mg (a medication used to treat prostate problems) for Resident 51 3. Omitted or late administration of fluoxetine 10 mg (a medication used to treat mental illness) for Resident 51 4. Omitted or late administration of Anoro Ellipta (a medication used to treat breathing problems) for Resident 51 5. Omitted or late administration of calcium carbonate (a supplement) 500 mg for Resident 51 6. Omitted or late administration of calcitriol (a medication used to treat low calcium for patients with bone or kidney disease) 0.25 mg for Resident 51 7. Omitted or late administration of sodium chloride (chemical name for salt; an electrolyte that regulates the amount of water in your body) 1 gram ([gm] a unit of measure for mass) for Resident 257 8. Omitted or late administration of risperidone (a medication used to treat mental illness) 3 mg for Resident 257 9. Late administration of Admelog (a type of insulin used to treat high blood sugar) for Resident 200 10. Wrong dose of vitamin C (a supplement) administered for Resident 200 11. Wrong dose of vitamin D3 (a supplement) administered for Resident 200 12. Omitted or late administration of clopidogrel (a medication used to prevent stroke) 75 mg for Resident 200 13. Omitted or late administration of multivitamin (a supplement) for Resident 200 14. Omitted or late administration of ferrous sulfate (a supplement) for Resident 200 15. Omitted or late administration of sodium chloride 1 gm for Resident 200 16. Omitted or late administration of zinc sulfate (a supplement) 220 mg for Resident 200 17. Omitted or late administration of lactobacillus (a supplement) for Resident 200 This deficient practice of failing to administer medications in accordance with the physician's orders increased the risk that Residents 51, 200, and 257 may have experienced serious medical complications such as stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts) or complications related to poor blood sugar or blood pressure control possibly resulting in hospitalization and/or death. This deficient practice of failing to administer psychiatric (relating to mental illness or its treatment) medications to Residents 51 and 257 could have resulted in a psychiatric emergency possibly threatening the resident's safety, the safety of other residents, and facility's staff. On 1/25/2023 at 4:08 p.m., in the presence of the Administrator (ADM), Director of Nursing (DON), and the Assistant Administrator (AADM) an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation was identified, and declared due to the facility's failure to ensure that its medication error rate was less than 5%. The medication error rate was 38.64 % On 1/27/2023 at 12:26 p.m., the facility provided the Department of Public Health with an Immediate Jeopardy Removal Plan (IJRP) containing the following summarized actions: 1. On 1/25/2023 at 4:30 p.m., a change of condition was initiated for Residents 51, 200, and 257. Residents will be monitored for side effects of medication omissions for 72 hours and any adverse reaction shall be reported timely to the physician. A plan of care for medication omission was initiated. The Medical doctor and responsible party were informed of the resident change in condition. Medications that were not available for Residents 51, 200, and 257 were ordered from the pharmacy by the licensed staff. 2. On 1/25/2023 at 6 p.m., the facility began a medication cart audit of the residents' medication by checking each resident medication order and checking the availability of the medication in the medication cart. 3. In-service was initiated by the DON or designee on 1/25/2023 at 6 p.m. for licensed nurses regarding medication administration guidelines. 4. Medication pass competency skills check was initiated on 1/25/2023 by the DON or designee. 5. The DON or designee shall provide counseling, one-to-one in-service to licensed nurses involved with the deficient practice on medication administration guidelines starting on 1/26/2023. 6. Physician or nurse practitioner visits were scheduled for 1/26/2023. 7. The licensed nurses will be educated on the policy and expectation for the completion of accurate and timely documentation in the Medication Administration Record ([MAR] - a record of all medication administered to a resident). The education will also include medication ordering protocols to ensure that medications ordered by the physician are ordered and available for timely medication pass. 8. The licensed nurses will be educated on the medication error policy and expectations. This education will include omitted medications, medications unavailable, errors in administration and medication not administered timely. 9. The facility contacted the pharmacy and scheduled an on-site assistance for training and monitoring. 10. The facility's medication administration guidelines were revised to include the role of the licensed nurse when ordering medications not available during med pass. On 1/28/2023 at 1:42 p.m., while onsite, after verification through observation, interview, and record review the facility's implementation of the IJ immediate corrective actions, the Immediate Jeopardy was removed, in the presence of the ADM, DON, and the AADM. Findings: a. During a concurrent observation of medication administration and interview with the Licensed Vocational Nurse 1 (LVN 1) on 1/25/2023 at 8:28 a.m., LVN 1 was observed preparing the following medications for Resident 51: 1. One tablet of amlodipine (a medication used to treat high blood pressure) 5 mg 2. One multivitamin tablet 3. One tablet of vitamin B1 100 mg (a supplement) 4. Two tablets of vitamin D3 1000 international units (IU - a unit of dose for vitamins) 5. One tablet of Farxiga (a medication used to treat high blood sugar) 10 mg 6. One tablet of finasteride (a medication used to treat prostate problems) 5 mg LVN 1 stated Resident 51 also has physician orders for metoprolol succinate 50 mg, tamsulosin 0.4 mg, and fluoxetine 10 mg due to be administered at 9 a.m., but they are currently out of stock. LVN 1 stated the pharmacy was supposed to automatically send medication refills, but she does not know why the medications were not there. LVN 1 stated she will follow-up with the pharmacy to obtain the missing medications right away. During an observation on 1/25/2023 at 8:50 a.m., the following was observed of the pharmacy's labels: 1. The pharmacy label on the empty medication bubble pack (a card prepared by the pharmacy containing the individual doses of medications) for metoprolol succinate 50 mg showed it was last refilled for a fourteen day-supply on 12/26/2022. 2. The pharmacy label on the empty medication bubble pack for fluoxetine 5 mg showed it was last filled for a fourteen day-supply on 12/27/2022. 3. The pharmacy label on the empty medication bubble pack for tamsulosin 0.4 mg showed it was last filled for a 30 day-supply on 12/20/2022. During an interview on 1/25/2023 at 8:57 a.m., LVN 1 stated the six medications listed above were the only medications to administer to Resident 51 that morning besides the missing metoprolol succinate 50 mg, tamsulosin 0.4 mg, and fluoxetine 10 mg. LVN 1 stated she ordered the missing medications from the pharmacy and will administer them later when they arrive. During an observation on 1/25/2023 at 9 a.m., Resident 51 was observed taking all six medications listed above by mouth with water. A review of Resident 51's Admission Record ([AR] a document containing demographic and diagnostic information), dated 1/25/2023, the AR indicated Resident 51 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 51's diagnoses included essential hypertension (high blood pressure), Type 2 diabetes mellitus (a medical condition characterized by the body's inability to control blood sugar levels), major depressive disorder (a mental illness characterized by changed in mood, lack of energy, social withdrawal, and lack of interest in usually enjoyable activities), and chronic kidney disease (loss in kidney function over time leading to waste and fluid buildup in the blood.) A review of Resident 51's Order Summary Report (a list of all currently active medical orders), dated 1/25/2023, the summary report indicated Resident 51 also had the following medications due to be administered every day at 9 a.m.: 1. Anoro Ellipta - inhale one puff by mouth once daily 2. Calcitriol 0.25 mg by mouth once daily 3. Calcium carbonate 500 mg by mouth three times daily b. During an observation of medication administration with LVN 1 on 1/25/2023 at 9:03 a.m., LVN 1 was observed preparing the following medications for Resident 257: 1. One tablet of metformin (a medication used to control blood sugar )1000 mg 2. One and one-half tablets of fluvoxamine (a medication used to treat mental illness) 100 mg 3. One tablet of clonazepam (a medication used to treat mental illness) 1 mg 4. One tablespoon of a fiber supplement (a supplement used to aid bowel movements) mixed in approximately 4 ounces of water 5. One multivitamin tablet 6. One tablet of sennosides (a laxative used to aid bowel movements) 8.6 mg 7. One tablet of finasteride 5 mg 8. One capsule of tamsulosin 0.4 mg 9. Three and one-half tablets of quetiapine (a medication used to treat mental illness) 100 mg During an interview on 1/25/2023 at 9:16 a.m., LVN 1 stated the nine medications listed above were the only mediations to administer to Resident 257 that morning. During an observation on 1/25/2023 at 9:21 a.m., Resident 257 was observed taking all nine medications listed above with water. A review of Resident 257's AR, dated 1/25/2023, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus, schizophrenia (mental illness characterized by hearing and seeing things that are not there), and schizoaffective disorder, bipolar type (a mental illness characterized by hallucinations, delusions, and mood swings between mania and sometimes depression). A review of Resident 257's Order Summary Report, dated 1/25/2023, the summary report indicated Resident 257 also had the following medications due to be administered every day at 9 a.m.: 1. Sodium Chloride 1 gm by mouth one time a day 2. Risperidone 3 mg by mouth by mouth two times a day c. During an observation of medication administration with LVN 2 on 1/25/2023 at 9:33 a.m., LVN 2 was observed preparing 18 units (a measure of dose for insulin) of Admelog for Resident 200. During an observation on 1/25/2023 at 9:38 a.m., LVN 2 was observed administering 18 units of Admelog insulin by subcutaneous (under the skin) injection into Resident 200's left lower abdomen. During an observation of medication administration and concurrent interview with LVN 2 on 1/25/2023 at 9:42 a.m., LVN 2 was observed preparing the following medications for Resident 200: 1. One tablet of Farxiga 10 mg 2. One tablet of icosapent ethyl (a medication used to lower cholesterol) 1 gm 3. One tablet of losartan (a medication used to treat high blood pressure) 25 mg 4. One tablet of magnesium oxide (a supplement) 5. One tablet of metformin 1000 mg 6. One tablet of metoprolol tartrate (a medication used to treat high blood pressure) 25 mg 7. One tablet of vitamin B-6 (a supplement) 25 mg 8. One tablet of vitamin C 500 mg 9. One tablet of vitamin D3 5000 IU (An international unit (IU) an internationally accepted amount of a substance). LVN 2 stated Resident 200 should also receive one tablet of zinc sulfate 220 mg, one tablet of ferrous sulfate, one tablet of lactobacillus, and one tablet of sodium chloride 1 gm at 9 a.m. but she did not have those medication available in the medication cart. LVN 2 stated she was planning on obtaining those medications later and would return to administer them. During an interview on 1/25/2023 at 9:54 a.m. with LVN 2, LVN 2 stated the nine medications listed above were the only medications to administer to Resident 200 that morning besides the missing zinc sulfate, ferrous sulfate, sodium chloride, and lactobacillus. During an observation on 1/25/2023 at 9:56 a.m., Resident 200 was observed taking all nine medications listed above by mouth with juice. A review of Resident 200's AR, dated 1/25/2023, the AR indicated Resident 200 was admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including Type 2 diabetes, dysarthria (difficulty speaking caused by brain damage,) following cerebral infarction (slow or slurred speech due to a stroke), and essential hypertension. A review of Resident 200's Order Summary Report, dated 1/25/2023, the summary report indicated Resident 200 also had the following medications due to be administered at 9 a.m. every day: 1. Clopidogrel 75 mg by mouth one time a day 2. Multivitamin by mouth one time a day A review of Resident 200's physician order for Admelog insulin, dated 9/9/2022, the order indicated 18 units were to be injected subcutaneously twice daily with breakfast and lunch at 7:15 a.m. and 12 p.m., respectively. A review of Resident 200's order for vitamin C, dated 7/29/2022, the order indicated the prescribed dose was 1000 mg by mouth one time a day. A review of Resident 200's physician order for vitamin D3, dated 9/10/2022, the order indicated the prescribed dose was 2000 IU by mouth one time a day. During an interview on 1/25/2023 at 10:04 a.m. with LVN 1, LVN 1 stated metoprolol succinate, tamsulosin, and fluoxetine for Resident 51 have not yet arrived from the pharmacy and have not been administered. LVN 1 stated the medications would now be considered late even if they are administered later today because medication scheduled for a 9 a.m. administration was due one hour before or after the scheduled time to be considered on time (between 8 a.m. and 10 a.m.). During an interview on 1/25/2023 at 10:13 a.m. with LVN 2, LVN 2 stated she should have checked to see if all the medications for Resident 200 were available prior to starting his medication administration. LVN 2 stated the ferrous sulfate, lactobacillus, sodium chloride, and zinc sulfate would now be considered late because they are scheduled for 9 a.m. and will be administered after 10 a.m., LVN 2 stated it was important to make sure she has all medications available before beginning the medication administration to reduce the risk the resident may miss those medications entirely because the nurse forgets to go back and administer them later. A review of Resident 51's Medication Administration Record ([MAR] a record of all medication administered to a resident), for the month of 1/2023, the MAR indicated LVN 1 marked Anoro Ellipta, calcium carbonate, and calcitriol as administered in the record for 9 a.m. on 1/25/2023. A review of Resident 257's MAR for the month of 1/2023, the MAR indicated LVN 1 marked risperidone and sodium chloride as administered in the record for 9 a.m. on 1/25/2023. During an interview on 1/25/2023 at 12:04 p.m. with LVN 1, LVN 1 stated metoprolol succinate, fluoxetine and tamsulosin have still not arrived from the pharmacy for Resident 51. LVN 1 stated she administered the Anoro Ellipta late (after 10 a.m.) for Resident 51 because she saw it on the MAR and remembered she did not administer it. LVN 1 stated she failed to administer the calcium carbonate or the calcitriol because she overlooked them. LVN 1 stated she marked the MAR that calcium carbonate and calcitriol were administered to Resident 51 even though they were not because she was nervous. LVN 1 stated there was currently no supply of calcitriol 0.25 mg capsules for Resident 51 available in her medication cart or anywhere else in the facility. LVN 1 stated she failed to administer the sodium chloride and risperidone to Resident 257 even though she also marked the MAR they were administered at 9 a.m. LVN 1 stated there was currently no supply of risperidone for Resident 257 in her medication cart or anywhere else in the facility. LVN 1 stated the failure to administer medications ordered by the physician may cause medical complications resulting in hospitalization or death. LVN 1 stated failure to administer psychiatric medications, including antipsychotics (psychiatric medication which are available on prescription to treat psychosis), could cause residents to experience psychiatric emergencies which could endanger the safety of that resident, other residents, or facility staff. LVN 1 stated documenting the MAR inaccurately in a way that it does not reflect care the resident received may mislead prescribers to make unnecessary dosage changes to medications possibly resulting in further medical complications. During an interview on 1/25/2023 at 12:21 p.m. with LVN 2, LVN 2 stated she administered the ferrous sulfate, zinc sulfate, sodium chloride, and lactobacillus around 11 a.m. LVN 2 stated these were given late as they were due by 10 a.m. LVN 2 stated medications must be given within one hour before or after their prescribed administration time to be considered on time. LVN 2 stated she administered the Admelog to Resident 200 late because it was due at 7:15 a.m. but administered closer to 10 a.m. LVN 2 stated the latest it could be given to be considered on time would be 8:15 a.m. LVN 2 stated she administered the wrong dose of vitamin C to Resident 200 as she gave 500 mg instead of 1000 mg. LVN 2 stated she administered the wrong dose of vitamin D3 to Resident 200 as she gave 5000 IU instead of 2000 IU. LVN 2 stated she failed to administer the multivitamin and clopidogrel to Resident 200 because she overlooked them. LVN 2 stated failing to administer clopidogrel could put Resident 200 at risk for a stroke which could lead to hospitalization or death. LVN 2 stated failure to administer insulin on time could lead to medical complications due to poor blood sugar control. LVN 2 stated failure to administer medications, or the correct doses of medications could result in medical complications possibly resulting in hospitalization . During an interview on 1/25/2023 at 3:44 p.m. with the DON, the DON stated the facility just transferred to an electronic medication refill system with their pharmacy. The DON stated the pharmacy was supposed to receive the refill order about three to four days ahead of time automatically based on the day-supply of medication previous dispensed for the residents. The DON stated the pharmacy can usually deliver those refills the next day. The DON stated if the electronic system fails, the nurses are responsible to notify the nurse supervisor or the pharmacy to request a refill for the resident. The DON stated neither he nor his staff conducts any oversight, such as periodic audits, of the pharmacy refill process to ensure it is working correctly but relies on the licensed staff to notify the pharmacy when medications are low to request a refill. The DON stated the facility leadership should implement some sort of oversight process due to residents being found without medications available for which they have active orders. The DON stated failing to administer medication according to the physician's orders may cause medical complications possibly resulting in hospitalization or death. The DON stated he was unaware licensed staff were falsifying entries on the MAR to indicate medications were administered when they were not even available in the facility. The DON stated he would determine which nurses were responsible for the falsified MAR entries and provide them one-on-one counseling and discipline as necessary. The DON stated the MAR must accurately reflect care provided to the residents otherwise it could cause medical providers to make unnecessary dosage changes to medications that could result in poor outcomes for the residents negatively affecting their quality of life. During a review of the facility's policy and procedure (P/P), dated 4/2008 and titled Medication Administration - General Guidelines, the P/P indicated Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . Medications are administered in accordance with written orders of the attending physician . Medications are administered within 60 minutes of scheduled time (an hour before and an hour after), except before or after meal orders, which are administered based on mealtimes . The individual who administered the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented. During a review of the facility's P/P, dated 11/2017 and titled, Medication and Treatment Administration Record, the P/P indicated Medications and treatments shall be administered as prescribed by the physician and shall be recorded by the responsible licensed nurse as the medication and/or treatment is provided. The attending physician shall be notified in the event an order cannot be administered as prescribed. A review of the facility's P/P revised 11/2017 and titled, Medication Errors, the P/P indicated It is the policy of this facility that medication errors will be reported to the resident, his/her physician and to the resident/resident representative . A medication error is defined as administration to a resident: At the wrong time . at the wrong dose . omission of the prescribed medication (unless refused by the resident) . When first discovered, the medication error shall immediately be reported to the physician for appropriate actions to be taken.

Based on interview and record review, the facility's staff failed to ensure one of three sampled residents (Resident A) was free from physical abuse. The facility failed to: 1. Ensure staff members supervised residents' smoking activity to prevent physical altercations and abuse, per the facility's policy titled Smoking Policy. Residents A and B were left unsupervised on the Grove Unit (a locked unit were residents with more aggressive behavior, elopement/exit seeking [leaving without permission] resided and where CPI [crisis prevention intervention] trained staff were available to handle critical behaviors) smoking patio during a smoking activity. Resident B physically assaulted Resident A, which resulted in an injury to Resident A's right index finger. This deficient practice resulted in an unwitnessed physical assault/abuse on Resident A by Resident B, who grabbed Resident A's right hand and pulled his finger resulting in a fractured (broken bone) finger and placed other residents at risk for potential physical abuse. Findings: During a review of Resident A's Admission Records (Face Sheet), the Face Sheet indicated Resident A was initially admitted to the facility on [DATE], and last readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident A's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/1/2021, the MDS indicated Resident A was able to make independent decisions that were consistent and reasonable. According to the MDS, Resident A required limited one-person physical assistance from staff for locomotion (moving) on and off the unit but did not walk in his room or the corridor. The MDS indicated Resident A had a functional limitation in range of motion ([ROM] the distance and direction a joint can move to its full potential) to one of his lower extremities (left leg). During a review of Resident A's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident A's Nursing Progress Note (NPN), dated 1/17/2022 and timed at 10:45 p.m., the NPN indicated Resident A approached Licensed Vocational Nurse 1 (LVN 1) and reported that while he was smoking on the patio, Resident B asked him if he could have a light. The NPN indicated Resident A told Resident B No, and Resident B grabbed Resident A's right hand and jerked it sideways. Resident A's right index finger was noted with swelling and stiff to touch, and Resident A complained of pain of 10 on a scale of 1-10 (10 indicating extreme pain) and was unable to move the affected finger. Resident A's physician was called, and an order was obtained for an x-ray (a photographic or digital image of the body part internal composition) of the right hand. During a review of Resident A's Physician Order, dated 1/17/2022, the order indicated to obtain a STAT (immediate) x-ray of Resident A's right hand. During a review of Resident A's x-ray Report, dated 1/18/2022, the x-ray report indicated Resident A had an acute (recent) oblique (slanting/twisted) second proximal (the part of the body that is closer to the center of the body than another part) phalanx (a bone of the finger or toes) fracture with mild displacement (loss of bone alignment). During a review of Resident A's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident B's Admission Records (Face Sheet), the Face Sheet indicated Resident B was initially admitted to the facility on [DATE] and last readmitted on [DATE]with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident B's MDS assessment, dated 12/14/2021, the MDS indicated Resident B's cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident B required limited one-person physical assistance from staff to walk in his room and down the corridors and on/off the unit. During a review of Resident B's physician orders, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (antipsychotic medication) tablet 3 milligram (mg) every 12 hours related to (r/t) [CONDITION(S)] disorder, [CONDITION(S)] type m/b disorganized thought process. 2. [MEDICATION(S)] tablet 600 mg at bedtime r/t [CONDITION(S)] disorder, [CONDITION(S)] type m/b responding to internal stimuli (unseen; i.e. voices etc. with a response) and talking to self. During a review of Resident B's NPN, dated 1/17/2021 and timed at 10:56 p.m., the NPN indicated LVN 2 was informed by a charge nurse (unnamed), Resident B grabbed Resident A's hand because Resident A refused to give Resident B a light for his cigarette when he asked. During a review of the facility's Investigative Report (IR) dated 1/18/2022 and timed at 9:30 a.m., the IR indicated Resident A stated he was outside smoking a cigarette in the patio unattended at approximately 9:30 p.m., on 1/17/2022. Resident A stated Resident B approached him and asked for a cigarette. Resident A stated No to Resident B became angry and grabbed Resident A's right wrist and pulled Resident A's right index finger sideways. During a telephone interview on 4/15/2022 at 3:13 p.m., the Director of Nursing (DON) stated after reviewing LVN 1's nursing notes dated 1/17/2022, she found a certified nursing assistant (CNA 1) was mentioned by LVN 1 in his notes. The DON stated she called LVN 1 and LVN 1 stated CNA 1 was supervising the smoking patio but was pulled away on an emergency and that was when the altercation happened between Residents A and B. During a telephone interview on 4/24/2022 at 7:13 p.m., Registered Nurse Supervisor 1 (RNS 1) stated, the last smoking hour for the residents was at 8:30 p.m. and based on the slowest smoker the smoking break typically last approximately, 30 minutes. RNS 1 stated the smoking hours are usually followed so residents have consistency. RNS 1 stated he did not know who was assigned to the smoking patio but was told it was CNA 1. During a telephone interview on 4/25/2022 at 12:09 p.m., CNA 1 stated the night of the incident (1/17/2022) between Residents A and B he was assigned to the patio area. CNA 1 stated there were approximately four residents who were either smoking or lingering around the patio after they finished smoking. CNA 1 stated he heard a resident hollering across the hallway and ran to that area to make sure no one was hurt. CNA 1 stated when he returned to the smoking patio, Residents A and B were close to each other, but he was not aware there had been an incident between them until LVN 1 asked him if he had seen anything. CNA 1 stated when he is assigned to monitor the smoking patio, he monitors the residents for safety to make sure there are no resident-to-resident altercations, falls, and/or smoking related accidents. CNA 1 stated the residents who were on the smoking patio were not being aggressive and he had no reason to believe any of them would become aggressive so when he heard the other resident holler out his priority was to make sure that resident was okay. CNA 1 stated the last official smoking time was at 8:30 p.m., but even after the last smoking time they allow residents to smoke and monitor them until the end of the shift. During a telephone interview on 4/25/2022 at 12:51 p.m., Licensed Vocational Nurse 1 (LVN 1) stated he was passing medication the night of the altercation on 1/17/2022, when Resident A approached him and stated he missed his smoking break. LVN 1 stated he had cigarettes on him and gave one to Resident A who went to the smoking patio to smoke. LVN 1 stated later, Resident A came to him pointing at his right hand and stated Resident B grabbed his hand. LVN 1 stated Resident A's finger was hard and swollen and Resident A was in a lot of pain. LVN 1 stated he asked CNA 1 what happened, and CNA 1 told him he was not on the patio and did not witness the altercation between Residents A and B. LVN 1 stated he was not sure if the facility was short-staffed that night but stated CNA 1 left the patio and should have stayed on the smoking patio where he was assigned to monitored and supervise. During a review of the Grove Smoking Schedule Times, the schedule indicated resident's smoking times were at 6:30 a.m., 8:30 a.m., 1:45 p.m., 3:30 p.m., 6:30 p.m., and 8:30 p.m. During a review of the facility's policy and procedure (P/P), dated 10/24/2017 and titled, Smoking Policy, the P/P indicated the purpose was to respect residents' choice to smoke and to maintain a safe and healthy environment to both smokers and non-smokers. The P/P indicated designated supervised smoking schedule will be discussed with the residents and posted in the facility and all smoking sessions will be supervised by the facility's staff members. During a review of the facility's P/P for abuse, revised in 3/2018 and titled, Abuse Prohibition and Prevention, the P/P indicated each resident had the right to be free from abandonment, mental/emotional, isolation, involuntary seclusion, verbal, physical, financial, sexual, neglect, and misappropriation of property.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident was free from physical abuse (Resident 2). Resident 1, who has a history of aggressive physical assaultive behavior with intent (resolved or determined to do [something]) was not supervised in the patio and pushed and kicked Resident 1 in the back. The facility failed to implement the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 and Resident 2 continued to share the same bathroom and other common spaces. This failure resulted in Resident 2 being afraid and feeling mental anguish (a high degree of mental pain and distress; anxiety, embarrassment, or anger of such a severity that it causes a substantial disruption in the injured person's daily routine), and pain to the back and legs with decreased mobility requiring a wheelchair for mobility. On 11/9/2021 at 5:13 p.m., the Administrator (ADM) and the Director of Nursing (DON) were notified of the Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation that was called for the facility's failure to ensure Resident 2 was free from abuse F600. On 11/10/2021 at 4:12 p.m., the ADM and DON submitted an acceptable Plan of Action (POA) for the correction of the IJ, which included: 1. Resident 2 was referred to physical therapy for evaluation and appropriateness of wheelchair use on 11/9/2021. 2. Education was provided to licensed nurses by the DON/Designee on 11/10/2021 regarding Change of Condition (COC) including documentation of COC and notification of physicians. 3. Resident 1 was transferred to the hospital on 10/13/2021 for a psychiatric evaluation. 4. An order was obtained on 11/9/2021 [sic] from the psychiatrist to transfer Resident 2 to another building if possible. Resident 1 and Resident 2 were moved to separate halls in the Palm Grove building on 11/14/2021. Resident 2's transfer to another building attempted on 11/10/2021, however resident is currently refusing to move. 5. Resident 2 was referred to a psychologist for potential psychological impact on 11/10/2021. 6. Resident 1 and Resident 2 were referred to a psychiatrist for evaluation on 11/9/2021. The facility obtained orders for medication adjustments and labs from the psychiatrist on 11/9/2021. 7. Education provided by DON/Designee to department managers and licensed staff on 11/10/2021 regarding resident-to-resident altercation management: separate residents, physicians/psychiatrists are notified, and aggressor is referred for psychiatric evaluation. Aggressor is placed on 1:1 monitoring for safety. Physicians' orders are obtained and followed. Victim is monitored for potential emotional distress related to incident. 8. The Interdisciplinary Team ([IDT] the members of the treatment team to coordinate care and to document the communication among all members of the team) discusses resident to resident altercations daily in stand up including interventions and recommendations to prevent future altercations. Findings reported monthly to quality assurance ([QA] measures compliance against certain necessary standards) for three months. 9. Social services assistant (SSA) provided Resident 1 with education regarding conflict resolution and ways to cope with feelings and frustrations, encouraged resident to participate in activities to redirect their attention for positive and enjoyable outcomes 11/10/2021. 10. Residents 1 and 2's care plans were updated on 11/10/2021. 11. Social Services Staff to continue to provide emotional support as needed and encourage resident to ask for assistance to resolve any concerns related to their safety. On 11/10/2021 at 10:54 a.m., the ADM provided an acceptable plan of action (POA). During an observation, interview, and record review, while onsite, the ADM and the DON were notified the IJ was lifted, after the team verified the POA was followed and implemented. Findings: a. During a review of Resident 1's Admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and screening tool, dated 2/26/2021, the MDS indicated Resident 1 had moderate cognitive impairment (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 1 required supervision (oversight, encouragement, and cueing) with bed mobility, transfer, walk in room/corridor, eating and toileting. Resident 1 required limited assistance (staff provide guided maneuvering of limbs and other non-weight bearing assistance) for locomotion off unit (how resident moves to and returns from off-unit locations (areas such as dining, activities). During a review of Resident 1's untitled care plan, revised on 1/3/2021, the care plan indicated the resident had identified needs and behaviors which may lead to increased conflict with other peers/residents/staff and possible neglect and behaviors of pushing peers. The staff's interventions included but not limited to identifying increasing or escalating behaviors that require reevaluation and to identify specific behaviors that places resident at risk for aggression (hostile or violent behavior or attitudes toward another; readiness to attack or confront). During a review of the facility's undated document titled, Incidents by Incident Type, the document indicated Resident 1 had a physical aggressive incident on 1/7/2021 at 4:05 p.m. striking another resident. During a review of Resident 1's Behavior Note, dated 1/19/2021 and timed at 8:20 p.m., the note indicated Resident 1 was becoming difficult to redirect when she was following behind her peers being intrusive (causing disruption or annoyance through being unwelcome or uninvited) fighting with the air and throwing things within reach. The resident will not stay in her room to avoid issues. During a review of Resident 1's Behavior Note, dated 1/20/2021 and timed at 3:11 p.m., the note indicated Resident 1's behavior was intrusive toward peers and staff. The resident was seen kissing the pillar on the patio and continuing to be difficult to redirect, while arguing with peers. The Mental Health Worker (MHW) had to stop the resident (Resident 1) from striking peers daily. During a review of Resident 1's history and physical (H/P), dated 3/13/2021, the H/P indicated the resident has a history of Seasonal affective disorder ([SAD] a form of depression, seasonal depression, or winter depression) a problem with dementia (mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), depression, and a history of suicide attempt by trying to jump off a building. During a review of Resident 1's clinical psychologist (a professional who practices psychology and studies normal and abnormal mental states, perceptual, cognitive, emotional), dated 10/10/2021 and timed at 11 a.m. titled, Group therapy Progress Note, the note indicated Resident 1 displays elevated, irritable affect (severe form of unpredictable agitation), and anxious mood. The psychologist indicated Resident 1 meets the criteria of anxiety disorder (mental disorder with intense, excessive, and persistent worry and fear about everyday situations), decreased concentration, irritability, hypervigilance (state of heightened alertness accompanied by behavior that aims to prevent danger), fatigue, and worry. According to the psychologist note, Resident 1 has a history of aggressive speech and behaviors. During a review of Resident 1's Health Status Note, dated 10/13/2021 and timed at 11:20 a.m., the Health Status Note indicated Resident 1 had a physical aggression toward another resident (Resident 2). During a review of Resident 1's recapped physician orders, dated 10/15/2021, the order indicated a medication order placed on 3/7/2021 for [MEDICATION(S)] (medication is used to treat certain mental/mood disorder) 156 milligrams ([mg] unit of measurement) intramuscular injection (medication injected in the muscle) one time a day every 30 days related to [CONDITION(S)] disorder (mental health disorder that is marked by a combination of [CONDITION(S)] symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or [CONDITION(S)]). During a review of Resident 1's Medication Administration Records (MAR) from 1/2021 through 10/2021, the MARs indicated Resident 1 had many behavioral episodes and required redirecting, documented as follow: 1. In 1/2021, Resident 1 exhibited 58 episodes of grandiose delusions (false or unusual belief about one's greatness) of having usual powers, 61 episodes of paranoid delusions (irrational feeling that someone is intending to harm), 65 episodes of behaviors responding to internal stimuli (carrying on a conversation alone or behaving or interacting as if someone or something else is present), 27 episodes of slamming of doors, and 51 episodes of continuous pacing (walking nonstop). 2. In 2/2021, Resident 1 exhibited 13 episodes of responding to internal stimuli (odd, bizarre behavior such as smiling, laughing, or talking to oneself or being preoccupied). 3. In 3/2021, Resident 1 exhibited 80 episodes of continuous pacing. 4. In 4/2021, Resident 1 exhibited 16 episodes of responding to internal stimuli, 22 episodes of throwing personal items on peers, staff and on the floor. 5. In 5/2021, Resident 1 exhibited 114 episodes of responding to internal stimuli and 86 episodes of continuous pacing. 6. In 6/2021, Resident 1 exhibited 41 episodes of responding to internal stimuli and 81 episodes of continuous pacing. 7. In 7/2021, Resident 1 exhibited 93 episodes of responding to internal stimuli and 96 episodes of continuous pacing. 8. In 8/2021, Resident 1 exhibited 51 episodes of responding to internal stimuli and 91 episodes of continuous pacing. 9. In 9/2021, Resident 1 exhibited 89 episodes of responding to internal stimuli and 111 episodes of continuous pacing. 10. In 10/2021, Resident 1 exhibited 89 episodes of responding to internal stimuli and 88 episodes of continuous pacing. b. During a review of Resident 2's Admission Record (Face Sheet), the face sheet indicated Resident 2 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 required assistance with activities of daily living ([ADL] self-care such as feeding, bathing, dressing, and grooming oneself), supervision (oversight, encouragement and or cueing) with bed mobility, transfer, walk in room/corridor, locomotion on unit and off unit, dressing, eating, and toileting use. During an interview, on 10/13/2021 at 12:11 p.m., Licensed Vocational Nurse 10 (LVN 10) stated the facility has been short-staffed on the unit. LVN 10 stated there were only five (5) staff members (CNAs and LVNs) on the shift. LVN 10 stated 6-7 staff were needed to provide for the residents in Palm Grove Unit (a psychiatric locked unit), which houses 74 residents. LVN 10 stated usually there are only five staff members to provide care and monitoring to the residents. During an interview with Certified Nursing Assistant 1 (CNA 1) on 10/13/2021 at 2:10 p.m., CNA 1 stated, We are short-staffed today. During a review of the facility's investigation of an unusual occurrence documented by the SSA 1 indicated the following: 1. Interview with the resident (Resident 2) on 10/13/2021 at 11:45 a.m., the resident (Resident 2) stated she was on the patio when that crazy lady (Resident 1) kicked me for no reason. 2. Interview with Mental Health Counselor (MHC 2) on 10/13/2021 at 2 p.m., MHC 2 stated he heard a thump and saw the resident (Resident 2) was on the ground (on 10/13/2021). MHC 2 stated resident (Resident 2) stated Resident 1 hit her. 3. Interview with resident (Resident 2) on 10/14/2021 at 3 p.m., Resident 2 stated she would like to move rooms due to her sharing a bathroom with Resident 1. The resident (Resident 2) complained of pain and requested a wheelchair. 4. Outcome of the investigation, not dated, stated the resident (Resident 1) have unpredictable behaviors of aggressive, paranoid (suspicious, fearful) thoughts and assaultive secondary to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The investigation concluded both residents were on the patio when the resident (Resident 1) kicked the other resident (Resident 2) unprovoked (occurring without any identifiable cause or justification) on the right side of her back which resulted in Resident 2 falling to the ground. During an interview, on 10/14/2021 at 9 a.m., Resident 2 stated she was on the outside patio after nutrition hour (morning snack) and was walking to throw away her trash, when she was struck on the back by Resident 1 and fell to the ground. During on an interview on 10/15/2021 at 10 a.m., the DON stated the Social Services Assistant 1 (SSA1) reported the incident. The DON stated many residents have common aggressive behaviors that are not apparent until there is a trigger. The DON stated it was important for staff to learn the triggers. During an interview with SSA 1 on 10/15/2021 at 10:15 a.m., SSA 1 stated she reported the incident that occurred between Residents 1 and Resident 2 and was conducting the facility's investigation. During a review of Resident 2's Licensed Progress Note (LPN), dated 10/15/2021 and timed at 10:16 a.m., the LPN indicated Resident 2 complained of pain to the legs, spinal column (backbone) and rib cage (the bony frame formed by the ribs around the chest). Resident 2 stated she could not stand up. During a review of Resident 2's Change of Condition Evaluation (COC), dated 10/15/2021 and timed at 3:19 p.m., indicated the following: 1. Change of condition: complaint of pain 3/10 ([pain scale] 0 being no pain and 10 being the worse pain) to right leg, bilaterally ribs, and spine. 2. Resident (Resident 2) was given Tylenol (medication taken for mild pain relief) 500 mg in the a.m. and [MEDICATION(S)] (medication taken for mild pain relief) 400 mg in the afternoon. 3. Functional Status Evaluation: decreased mobility, recent onset and not resolving spontaneously. The resident (Resident 2) stated she is having trouble walking and is unable to stand up. During a review of Resident 2's clinical Psychologist Note (PN), dated 10/18/2021 and timed at 12:23 p.m., the PN indicated Resident 2 stated she was using a wheelchair due to her leg and back hurting after she was struck by another resident (Resident 1) and fell . Resident 2 stated she remains depressed and anxious about the incident. PN indicate that resident continued to display decreased social-interpersonal functioning, including social withdrawal, and decreased appropriate behaviors as well as delusions and paranoia. During a concurrent observation and interview, while on the facility's patio (Building A) on 10/19/2021 at 9:18 a.m., Resident 2 stated she does not feel safe in the facility and was concerned about her mobility. Resident 2 complained of pain to the right hip and rib cage. Resident 2 was sitting in a wheelchair and was using the wheelchair to move about the unit to patio. Resident 2 stated she was unable to walk due to pain and her body being severed after the fall. Resident 2 stated she started using the wheelchair after being pushed by the resident (Resident 1) and falling. During a telephone interview on 11/4/2021 at 1:33 p.m., Registered Nurse Supervisor 1 (RNS1), stated residents need close monitoring, especially while on the patio. RNS 1 stated residents must be monitored closely during smoking time and nutrition time, there should be at least two assigned staff, which can be a CNA and or Mental Health Counselor (MHC). During an interview on 10/21/2021 at 1:08 p.m., LVN 4 stated prior to the incident on 10/13/2021 of Resident 2 being pushed and kicked by Resident 1, Resident 2 was ambulatory (walked without assistance), but now she relies on the wheelchair to move around the unit and in her room. During a telephone interview on 11/4/2021 at 4:46 p.m., Resident 1's Psychologist 1 (P 1) stated Resident 1 continues to experience hallucinations and experiences [CONDITION(S)] (mental illness marked by periods of great excitement or euphoria, delusions, and overactivity). During a telephone interview with LVN 2 on 11/8/2021 at 1:25 p.m., LVN 2 stated as of that day (11/8/2021) Resident 2 was not walking and using wheelchair for locomotion. LVN 2 stated prior to the incident on 10/13/2021, Resident 2 walked independently. During a telephone interview with the DON on 11/8/2021 at 2:10 p.m., the DON stated she was not aware that Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the staff must anticipate resident behaviors to identify triggers that could cause residents to act aggressively. The DON stated resident behaviors can be unpredictable and the staff must be able to visually see all residents in the patio, residents must be in their line of sight. During a telephone interview with Residents 1 and 2's psychiatrist (a medical practitioner specializing in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The psychiatrist stated he was called by the nursing staff on 10/13/2021 after the incident regarding Resident 2 being kicked by Resident 1 on the patio. The psychiatrist stated he gave a verbal order to the nurse to separate the residents (Resident 2) in different buildings where they will not share a common area. During a concurrent observation and interview with Resident 2 on 11/9/2021 at 2:30 p.m., in Building A's patio, Resident 2 was in a wheelchair and stated she feels like she will fall without the use of the wheelchair. Resident 2 stated she does not feel safe because she was pushed by a woman. Resident 2 stated, My back, hip and pelvis are broken, and my spine is severed by healing. Resident 2 stated she feels like she can be harmed again and wants to go home to her family. There was no staff observed supervising the residents. During an interview with LVN 1 on 11/10/2021 at 1:35 p.m., LVN 1 stated Residents 1 and 2 remain in the same building (Building A) and Resident 2 have not been moved to another building as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the facility's policy and procedure (P/P), revised in 3/2018 and titled, Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime in the Facility Policy and Procedure the P/P indicated residents must not be subjected to abuse by anyone, including but not limited to, facility, staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals.

Based on interview and record review, the facility failed to ensure adequate supervision was provided for one of one sampled resident (Resident 1). A physical therapist ([PT 1], a licensed medical professional with experience in diagnosing physical abnormalities, restoring physical function and mobility, maintaining physical function and promote physical activity and proper function), recommended for Resident 1 to have more supervision (stand by assist [close supervision]) due to a new onset of a decrease in functional mobility after a fall (9/20/2020). Resident 1 had another fall after walking unsupervised on 10/7/2020 without a stand-by assist and sustained injuries. This deficient practice resulted in Resident 1 having a second fall and sustaining a scalp hematoma (collection of blood) and a nasal (nose) fracture (broken bone), requiring a transfer to a general acute care hospital (GACH) and being closely monitored in intensive care (ICU). Findings: During a review of Resident 1's Admission record, the Admission record indicated Resident 1 was admitted on [DATE] with diagnoses including Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), muscle weakness with abnormalities of gait (person's manner of walking), and a history of falls. During a review of Resident 1's Care plan for high risk for falls and injuries dated 1/2/2020, the care plan indicated the facility should anticipate and meet the resident's needs. During a review of Resident 1's Minimum Data Set (MDS), a comprehensive standardized assessment and care-screening tool, dated 9/29/2020, the MDS indicated Resident 1 had severely impaired cognitive skills (thought process) for daily decision-making. The MDS indicated Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) for bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed) and toilet use, extensive assistance (resident involved in activity; staff provide weight-bearing support) for dressing and personal hygiene. According to the MDS, Resident 1 had two or more falls with minor injuries such as skin tears, abrasions, lacerations, hematomas, and sprains. During a review of Resident 1's Fall Risk Assessment, dated 9/20/2020, the Fall Assessment indicated Resident 1 had a score of 8 which was a moderate risk for fall (16-26 is high risk; 6-15 is moderate risk; 1-5 is low risk). During a review of Resident 1's care plan, dated 9/20/2020 indicated the resident had a fall and was found on the floor next to his bed and sustained a laceration (deep cut) over the right eyebrow. During a review of Resident 1's Oder Summary report for the month of 9/2020, there was a physician order to cleanse the eyebrow laceration measuring 0.5 centimeter (cm) by 0.5 cm with normal saline (a mixture of salt and water), pat dry, apply triple antibiotic ointment (used to treat infections) and leave open to air for 14 days. During a review of Physical Therapy (PT) Evaluation and treatment plan, dated 9/22/2020, the PT Evaluation indicated Resident 1 had a new onset of decrease in strength, functional mobility, reduced ability to safely ambulate, reduced functional tolerance, decreased coordination (the ability to use different parts of the body together smoothly and efficiently), and cognitive (thought process) deficits. The PT note indicated Resident 1 was referred to PT after a fall on 9/20/2020 with injury. During an interview and concurrent review of Resident 1's PT Discharge Summary note, dated 10/5/2020, the Director of Rehabilitation (DOR), stated Resident 1 was able to walk with stand by assist and staff should be next to the resident when ambulating for safety and supervision. The DOR stated training of the nursing staff was provided for safety precautions, fall prevention, and recovery techniques to decrease the risk for falls for Resident 1. During a review of Resident 1's Fall Scene Investigation Report, dated 10/7/2020, the Investigation report indicated Resident 1 had an unwitnessed fall while walking unassisted. According to the report, factors observed at the time of the fall was Resident 1 lost his balance. The report indicated under type of assistance Resident 1 was receiving at the time of fall, Resident 1 was alone and unassisted while walking. During a review of Resident 1's GACH Discharge Summary, dated 10/8/2020, the Discharge Summary indicated Resident 1 was seen in the GACH with a history of multiple falls with a recent ground level fall at the facility and was diagnosed with a frontal scalp contusion (a region of injured tissue or skin in which blood capillaries [fine branching blood vessels] have been ruptured; a bruise) and a nasal bone fracture. Resident 1 was admitted and closely monitored in the intensive care unit ([ICU] higher level of care) with repeated computerized tomography ([CT scan] combines a series of x-ray images taken from different angles around the body) of the head and face. Resident 1 was discharged from the GACH on 10/9/2020 back to the facility. During interviews on 11/30/2020 at 4:33 p.m. and 12/3/2020 at 4:24 p.m., Certified Nurse Assistant (CNA 1) stated Resident 1 spent most times in his room. CNA 1 stated she did not assist Resident 1 to get out of bed or when ambulating in his room. During an interview on 12/3/2020 at 4:44 p.m , Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was very confused. LVN 1 stated it was not safe for Resident 1 to get up and walk by himself. LVN 1 stated Resident 1 needed to be reoriented and redirected back to bed multiple times during the shift because Resident 1 would attempt to get out of bed without assistance. During an interview on 3/4/2021 at 4:50 p.m., the Director of Nursing (DON) stated Resident 1 had several factors that made him a high risk for falls including impaired memory, exit seeking and [CONDITION(S)] (relating to drugs that affect a person's mental state). During a review of the facility's undated policy and procedure (P/P) titled, Fall Management Program, the P/P indicated the facility must implement interventions to reduce the risk of falls.

Based on observation, interview, and record review, the facility's staff failed to implement infection control policies and procedures (P/P) and its mitigation plan which included response testing to prevent the spread of COVID 19 ([Coronavirus] a disease that can triggers a respiratory [lung] tract infection affecting the upper respiratory tract [sinuses, nose, and throat] and/or lower respiratory tract [windpipe and lungs] the virus spreads mainly through person-to-person contact) and Scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite) infections by ensuring the facility's staff practice hand hygiene, donned (put on) and doffed (removed) personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries) upon exiting the COVID 19 yellow zone (temporarily quarantined residents under surveillance for COVID 19 infection) for 163 of 163 residents. These deficient practices had the potential to spread infection of COVID-19 and scabies to staff, and visitors. During a review of the facility's census, the census indicated the facility had 163 in housed residents. On 10/18/2021 at 5:23 p.m., the State Agency (SA) declared an Immediate Jeopardy ([IJ], a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) for F880 and notified the facility's Administrator and Director of Nursing (DON) of the findings. On 10/19/2021 at 5:20 p.m., the SA removed the IJ in the presence of the Administrator and DON, after on-site verification of the implementation of the written Plan of Action ([POA], interventions to immediately correct the deficient practice) through observation, interview, and record review. The acceptable POA included the following: 1. Education initiated 10/18/2021 by Infection Prevention staff regarding process for crossing from yellow to green zone including proper use of face shields, disposal/doffing of PPE, hand hygiene, changing of gloves and gowns between residents and as needed. 2. Education initiated 10/18/2021 by Infection Prevention staff on the use of proper PPE prior to entering a contact isolation room to include proper donning and doffing of PPE: gloves and gown. 3. Education initiated on 10/18/2021 by DON Designee / Assistant DON regarding appropriate hand hygiene before and after resident care in an isolation room to include return demonstration. 4. Education initiated on 10/18/2021 by DON or Designee / Assistant DON to Infection Control Nurses regarding response testing of potential residents having been exposed to COVID-19. 5. Response testing of residents exposed to COVID-19 was completed 10/18/2021. 6. Response testing for all other residents was initiated 10/18/2021 to be completed by 10/20/2021. 7. Response testing for staff initiated 10/18/2021 to be completed 10/21/2021. 8. Education initiated on 10/18/2021 by Director of Staff Development to staff regarding redirecting residents to remain in the yellow zone and keep the face mask on all the time. 9. Residents will be visited by Activities staff on 1:1, initiated on 10/18/2021 for residents currently residing in the yellow zone regarding not leaving the yellow zone, and wear face masks at all times. 10. On 10/18/2021 contact isolation signs were placed outside the three resident rooms who had orders for contact isolation. 11. Education initiated on 10/18/2021 by Director of Staff Development regarding staff properly donning when entering a resident yellow room and doffing appropriately when exiting a resident yellow room. This education will be completed by 10/19/2021. 12. Quality Circle Rounds will be utilized as audit tools by Department Managers who will round at least 3 times per week for a minimum of 3 months to ensure compliance with infection control in-services. Findings: a. During an observation on 10/13/2021 at 8:38 a.m., during the initial tour of the facility, accompanied by the Director of Staff Development (DSD), two staff members were observed exiting the yellow zone wearing full PPE including face masks, face shield, gown with gloves, and entering into the green zone to obtain and/or request by yelling for additional supplies to provide care for an unknown resident in the yellow zone. The staff members were verbally informed by the DSD to return to the Yellow zone and supplies would be delivered. The staff returned to the yellow zone and stood by the double doors. During a subsequent observation on 10/13/2021 at 8:46 a.m., a Certified Nursing Assistant (CNA 13) was observed exiting the yellow zone with full PPE on including a face mask, gown, face shield, with gloves, and not practicing hand hygiene before entering the nursing station on the Green zone (COVID free) to request and / or obtain supplies. CNA 13 was standing inside of the nursing station and was notified by a Licensed Vocational Nurse (LVN 18) that The State was also sitting in the nursing station. CNA 13 quickly turned around to walk toward the yellow zone, LVN 18 stated to CNA 13 she would obtain the supplies he needed. During an observation of the Yellow zone on 10/13/2021 at 10:57 a.m., a Social Worker (SW 2) was observed exiting the yellow zone going into the Green zone without practicing hand hygiene. b. During an observation on 10/16/2021 at 4:48 p.m., the charge nurse (LVN 15) was observed sitting at the nursing station (next to the Yellow zone) without a face mask and/or a face shield. LVN 15 stated the mask and face shield both fell off, and she forgot to put them back on. During an observation on 10/16/2021 at 4:57 p.m., CNA 5 exited the Yellow zone and entered the dining room wearing a black surgical mask pulled down, with her nose exposed, and the face shield pushed back on her forehead, off her face, without practicing hand hygiene. CNA 5 walked directly into the dining room and sat down on a chair and removed her mask face and used her face shield as a fan to fan her face. CNA 5 was observed unmasked waving the used face shield up and down, while speaking to four unmasked residents who were seated in the dining area. During an interview on 10/16/2021 at 5 p.m., the Assistant Director of Nursing (ADON) stated CNA 5 was unmasked and using her face shield as a fan to cool down. ADON stated CNA 5 was not practicing proper infection control and may expose others to infection. ADON stated all staff should wear a face mask with a face shield all the time while in the facility. ADON stated she would speak with LVN 15 and CNA 5 and provide infection control education right away. c. During an interview with the facility's Infection Prevention Nurse 1 ([IP] responsible for the facility's activities aimed at preventing healthcare associated infections by ensuring that the source of infections were isolated to limit the spread of infectious organisms), on 10/18/2021 at 12:50 p.m., IP 1 stated she was made aware of Resident 62 testing positive for COVID-19 on 10/17/2021 at 7:30 p.m. when the resident was transferred to the general acute care hospital (GACH 1). IP 1 stated IP 3 was on duty on 10/17/2021 and initiated protocols and monitoring of the residents in the Yellow zone. IP 1 stated, Response testing plan was put together today, 10/18/2021, and will be started today. The plan is for 100% of staff to be tested . Response testing of residents will begin testing on 10/18/2021. IP 1 was unable to provide details of scheduling of resident's testing. During a review of Resident 62's Nurses Progress Note (NPN), the NPN indicated GACH 1 reported Resident 62's COVID-19 positive result to the facility on [DATE]. During an interview with IP 2 on 10/20/2021 at 3:58 p.m., IP 2 stated a delay in response testing can cause harm of potential COVID-19 exposure to other residents and staff. IP 2 stated IP 3 did not institute response testing on 10/17/2021 because he prioritized instituting droplet precautions (intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions, residents are quarantined to their rooms or designated area. Staff must wear appropriate PPEs). During an interview on 10/21/2021 at 1:25 p.m., IP 3 stated he was working on 10/17/2021, when he received confirmation Resident 62 tested positive for COVID-19 upon admission to GACH 1. IP 3 stated he notified the administrator immediately and ensured there were enough PPEs available and stocked, initiated COVID-19 droplet precautions and established a Yellow zone. IP 3 stated he did not start response testing and should have. IP 3 stated he refers to the guidance provided by the local health department and the facility's practice. IP 3 stated response testing should be started immediately. IP 3 stated immediately meant as soon as possible. IP 3 stated he was the only one working on 10/17/2021 and he would not have been unable to prepare kits to test 300 residents and to put in requisitions for more kits. IP 3 stated the delay in response testing had the potential for unnecessary exposure of COVID-19 to residents and staff. During an interview, on 10/21/2021 at 1:30 p.m., the Assistant Director of Nursing (ADON) stated the facility was short-staffed of IP nurses. The ADON stated the facility had three IP nurses but guidance from the local health department was to have five (5) IP nurses. During a review of an AFL titled, Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Testing of Health Care Personnel (HCP) and Residents at Skilled Nursing Facilities (SNF) dated 8/ , the AFL indicated Response Testing (repeat testing performed following exposure to COVID-19, goal of testing is to identify asymptomatic infections to prevent further spread of COVID-19. ) should be started as soon as possible after one (or more) COVID-19 positive individuals (resident or HCP) is identified in a facility. d. During a concurrent observation and interview with CNA 1 on 10/13/2021 at 8:51 a.m., a pink contact isolation sign on Resident 122's door indicated a gown and gloves were to be worn in the room, was observed at the entrance of Room A3. CNA 1 was observed in the contact isolation room wearing goggles, gloves, and a N95 respirator (a particulate-filtering facemask for air filtration [filters 95% of airborne particles]). CNA 1 was observed adjusting Resident 122 in bed and arranging Resident 122's items on the bedside table. CNA 1 then asked the resident's roommate (Resident 195) if he needed anything. CNA 1 was observed removing his gloves, exited the room, and performing hand hygiene. CNA 1 stated that the pink sign at the door of Room A3 indicated the resident in the room was on isolation. CNA 1 stated PPE was required in an isolation room. CNA 1 stated he should wear a gown, in addition to the gloves, goggles, and mask in the resident room. CNA 1 stated he did not wear a gown while in the room because he was rushing and did not put on a gown. CNA 1 stated he was unsure why the residents were on contact isolation. During a concurrent observation and interview on 10/13/2021 at 11:18 a.m., LVN 1 was observed removing the pink sign from Room A3. LVN 1 stated the scabies isolation was complete and was supposed to be removed. LVN 1 stated he was required to check the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 stated for contact isolation, the PPE required to donning prior to entering the room was gown, gloves, googles, and an N95 respirator. During a concurrent observation and interview on 10/14/2021 at 10:28 a.m., LVN 5 stated any resident with possible exposure to scabies was placed on contact precautions and treated with [MEDICATION(S)] (medication applied to the skin to treat scabies). LVN 5 stated there was not a contact precautions sign at the entrance of Room A3. LVN 5 stated the contact isolation was possibly discontinued by the infection preventionist (IP). LVN 5 stated since there was no contact isolation sign, the staff do not know what PPE to wear. LVN 5 confirmed there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 5 stated when the staff do not gown up, it creates risk of spreading scabies infection to ourselves and other residents. During an observation on 10/15/2021 at 9:43 a.m., there was no contact isolation signage at the entrance of Room A3. During an observation on 10/15/2021 at 1:12 p.m., there was no contact isolation signage at the entrance of Room A3. During a concurrent interview and record review on 10/18/2021 at 4:35 p.m., IP 1 stated Resident 122 had a current contact isolation order. IP 1 stated Resident 122's isolation order was to be discontinued 24 hours after the next [MEDICATION(S)] treatment. IP 1 stated an [MEDICATION(S)] treatment was scheduled for 10/22/2021. IP 1 stated Resident 195 was the roommate to Resident 122. IP stated Resident 195 had an active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . IP 1 stated the pink signage was to be posted at the entrance of the room to alert all staff what PPE was required prior to entering the room and there was no excuse for staff to not follow isolation precautions. IP 1 stated, I provided the registered nurse supervisors a list of contact isolation rooms daily and it was their responsibility to inform the charge nurses. IP 1 stated charge nurses are required to inform the CNAs. During a review of Resident 122's physician order, dated 10/9/2021, the order indicated for Resident 122 to be placed on contact precautions for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 195's physician order, dated 10/9/2021, the order indicated the resident was supposed to be on contact precautions for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/19/2021 at 9:40 a.m., the DON stated all staff have been educated on contact isolation precautions and donning and doffing. The DON stated staff should be donning a gown and gloves prior to entering a contact isolation room and in addition should already be wearing shield/goggles and a mask. The DON stated PPE should be worn inside the room even if not providing direct resident care. The DON stated if staff was not gowning up prior to entering the room, there was a high risk of transmitting infection. During a review of the facility's policy and procedure (P/P), revised 1/10/2019 and titled, Enhanced Standard Precautions, the P/P indicated a sign will be posted outside the resident's room to indicate special precautions are in place and needed when coming within three (3) feet of the isolated resident's environment. Resident's name and infectious organism will NOT be posted on the sign. Personal Protective Equipment will be stocked on or in a covered cart (to avoid contamination before use) outside the isolated resident's room for easy access before caring for isolated resident. Cart for PPE should not block egress from resident room. Hand hygiene before donning personal protective equipment. Don the appropriate PPE (gloves, gown at a minimum and add a mask if indicated) if planning to be within 3 feet of the resident or the resident's environment. Contact with environmental surfaces such as side rails, cubicle curtains etc. require donning of PPE as does contact with any of the resident care equipment. During care, change gloves after having contact with infective material (i.e. fecal material or wound drainage which may contain high concentrations of microorganisms). Change gloves when moving from one site to another (i.e. oral care, dressing change). The P/P indicated double-gloving is not an acceptable practice to avoid a glove change or a hand hygiene opportunity. Hand hygiene should be performed before donning and after removal of gloves each time gloves are used. Before leaving the room, remove gloves, gown, and other PPE. e. During an observation on 10/13/21 at 11:23 a.m., Residents 141 and 151's room was observed to have a sign outside the door indicating contact precaution (for patients with known or suspected infections that represent an increased risk for contact transmission) and there were no gowns, gloves, or masks available outside the door before entering the room. During an interview on 10/13/2021 at 11:24 a.m., LVN 18 stated the residents in Room F6 were on contact isolation for skin issues. During an observation on 10/13/2021 at 12:20 p.m., CNA 8 was observed entering Resident 141's room (an isolation room) to assist with feeding. CNA 8 did not perform hand hygiene prior to entering the room or put on a gown or gloves prior to assisting Resident 141. After CNA 8 was done assisting Resident 141 with his meal, CNA 8 was observed exiting the room without performing hand hygiene. During an interview on 10/13/2021 at 12:29 p.m., CNA 8 stated when entering a room with contact precautions, the first thing she needed to do was wash her hands. During a review of the facility's P/P, dated 1/10/2021 and titled, Hand Hygiene, the P/P indicated all employees are required to practice effective hand hygiene. Employees are encouraged to promote good hygiene with residents, visitors, and family members when appropriate. During a review of Resident 141's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 10/14/2021 at 10 a.m., CNAs 6 and 7 were observed assisting Resident 151 to the shower. CNA 7 was not wearing a gown. During an observation on 10/14/2021 at 10:04 a.m., CNA 7 was observed not wearing a gown while making up Resident 151's bed. During a review of Resident 151's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/18/2021 at 12:47 p.m., IP 1 was asked what the process was for entering contact isolation rooms, IP 1 stated all staff should use hand sanitizer, wash hands, and put on a gown and gloves when entering the room. During a review of the facility's COVID-19 Mitigation Plan Manual updated on 8/5/2021 indicated the following: 1. Staff will be trained on proper donning and doffing procedures. 2. Necessary PPE will be made available directly outside of resident rooms in the red and yellow zones in accordance with current CDC (Centers for Disease Control and Prevention) guidance. 3. All staff will wear recommended PPE while in the building percurrent, CDC or CDPH PPE guidance. 4. Residents leaving their room will be asked to wear a facemask, all residents leaving the facility for medical appointments will be sent with a facemask. During a review of the facility's P/P titled, Hand hygiene Policy and Procedure revised on 1/10/2019, the P/P indicated that all employees are required to practice effective hand hygiene. Employees are encouraged to promote good hand hygiene with residents, visitors, and family members when appropriate. Employees are required to wash their hands thoroughly before beginning the workday, between patients, between procedures on the same patient, after touching objects that may be soiled and after removing gloves, after removing gloves and any time hands become soiled, before meals, and after restroom use. During a review of the facility's P/P, dated 1/10/2019 and titled, General infection Prevention & Control, the P/P indicated infection surveillance shall cover the care center as a whole or targeted to specific buildings or nursing stations if the building or stations are separated geographically. Standard practice precautions will be practiced by all personnel and will be used for all residents all times. Intensified interventions is the third tier suggested for implementation by the CDC under circumstances such as when an unusual infectious agent is circulating in the community, or when the incidence of new cases of a specific infectious agent is either increasing or fails to decrease despite the implementation of and adherence to standard infection prevention procedures. Strategies to consider such as hand hygiene being the single most important precaution to prevent the transmission of infection from one person to another. Alcohol based hand rubs can be used as an adjunct to handwashing at times when soap and water are not easily accessible. Gather all equipment and supplies needed before entering the residents' rooms, only take needed supplies into the room. All PPE should be used once and either discard in the trash or used linen receptacle before leaving the room. Before leaving the room, remove gloves, gown, and other PPE.

Based on observation, interview, and record review, the facility's staff failed to ensure the residents who were at risk for choking and aspiration (breathing in a foreign object [food] into the airway) were supervised during eating and received their prescribed diet for four (4) of 35 sampled residents (Residents 58, 195, 30 and 88). a. Resident 58, who had a diagnosis of dysphagia (difficulty swallowing), had no teeth and exhibited behaviors of stealing food from other residents, had a history of choking that required emergency procedures, was not supervised, and took a sandwich not prescribed on Resident 58's diet texture and choked and was unable to be resuscitated (revived). b. Resident 195, who required assistance with eating and had a diagnosis of dysphagia, dementia (memory loss), gastro-[CONDITION(S)] reflux disease ([GERD] reflux of the stomach contents into the esophagus (the tube that carries food and liquids from your mouth to the stomach), causing heartburn and regurgitation (spitting up of food from the esophagus or stomach]), was observed eating while lying flat in bed with coffee spilled over the resident's clothing. c. Resident 30, who had diagnoses including dementia and dysphagia, a history of taking food and other objects and placing them into his mouth, was documented to be at risk for choking and aspiration. Resident 30 was observed unsupervised while putting sugar packets, gloves, and food in his mouth from another resident's tray. d. Resident 88, who had diagnoses including dysphagia, GERD, impaired cognition (thought process), was identified as being at high risk for choking and aspiration, was observed eating another resident's prescribed diet tray while eating unsupervised in the room. This deficient practice resulted in Resident 58, who had two prior choking episodes in the facility ([DATE] [donut] and [DATE] [cheese sandwich]) choked on a peanut butter sandwich and aspirated, leading to Resident 58's unexpected death. This deficient practice placed Residents 195, 30, and 88, who were at risk for choking and aspirating due to dysphagia, at risk for the potential of adverse consequences of harm and/or death. On [DATE] at 5:19 p.m., in the presence of Registered Nurse supervisor (RN 3), Administrator (ADM), and the Director of Nursing (DON), an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared due to lack of adequate supervision to prevent accidents of aspiration and chocking. On [DATE], the facility provided an acceptable Plan of Action (POA), which include the following actions: 1. The facility's licensed nurses will closely supervise residents with a prescribed diet and with behaviors of grabbing food from other residents or eating food incompatible with the prescribed diet during meals and snack times. A list of residents observed with a history of grabbing food will be provided in each nursing station. The licensed nurses will supervise the distribution of meals and snacks to ensure that meals and snacks are given to the correct resident and as prescribed. 2. The speech therapy (ST) screening was initiated on [DATE] for all residents (total of 60) on an advanced dysphagia diet, completed on [DATE]. 3. Speech Therapy evaluations were initiated on [DATE] for residents identified during the screening process to be completed by [DATE], with remaining residents pending insurance authorizations. The facility will downgrade diets for residents recommended for Speech Therapy evaluation due to the risk of aspiration. Any adverse findings will be communicated to the attending physician and the facility Medical Director. 4. Attending physicians were notified by [DATE] of the choking incident at the facility; physicians will inform the facility of residents at high risk of choking and/or aspiration and collaborate with the facility to update the plan of care during monthly visits. 5. An audit initiated on [DATE] by the Dietician and Assistant Dietician regarding all advanced dysphagia diets to ensure diets are current, food and snacks are labeled appropriately; audit completed on [DATE]. 6. The facility's licensed nurses to check food trays for proper diet before a Certified Nursing Assistant (CNA) distribute food trays to the residents. Director of Staff Development to an in-service facility licensed nurses on diet tray check and supervision during mealtime/nourishments. Initiated in-services on [DATE]; the goal of completion by [DATE]. 7. The Director of Staff Development (DSD) will make rounds and document licensed nurses' compliance and CNA competencies during mealtimes and report any findings to the Quality Assurance (QA) committee for three months. The QA Committee will evaluate results until substantial compliance is attained. 8. The licensed nurses will be stationed in the dining rooms and will round residents' rooms during mealtimes for residents requiring assistance during mealtime. The licensed nurses will also round in residents' rooms during meal and nourishment for three months. 9. In-services initiated by Dietician and the Assistant Dietician on [DATE] for the licensed nurses and CNAs on a review of the dysphagia advanced diet principles; reading meal tickets and snack labels; the importance of supervision and proper positioning during meals; checking for adaptive equipment on a tray, and reporting residents who have any difficulty chewing or swallowing to a nursing supervisor. Re-education was initiated on [DATE] with a goal of completion by [DATE]. 10. Initiated physicians' orders for all residents on advanced dysphagia diets for the head of bead (HOB) to be elevated to (high fowler position [lying on back with the head and trunk raised to between 15 and 45 degrees]) [DATE]. The goal is to complete by [DATE]. Occupational and Speech Therapy to reeducate CNAs on proper positioning; will initiate on [DATE]; the goal of completion by [DATE]. 11. The occupational therapist (OT) and speech therapist (ST) make daily rounds to assess any residents with difficulty swallowing. Rehabilitation Department will document any findings and report them to the Quality Assurance Committee for three months. Findings will be evaluated with the QA committee until substantial compliance is attained or observed. Daily results will be reported to the Administrator and Director of Nursing. 12. The facility's Medical Director will review any incidents related to choking at QA meetings monthly. The ST will assess residents quarterly and report any findings associated with swallowing at the QA committee. The Medical Director will be notified of residents at risk. The ST will report results on residents at risk for dysphagia for any decline or improvement monthly and report findings to the QA committee. 13. For the residents with advanced dysphagia, the facility created a task in the CNA's Plan of Care Daily Task to ensure the head of the bed is elevated during mealtimes and nourishments; initiated [DATE], the goal of completion by [DATE]. In addition, the ST and OT are assigned to do meal rounds to identify residents at risk for choking and to monitor residents who are currently on an advanced dysphagia diet to ensure the plan of care is in practice. The Administrator will monitor to ensure the POA is implemented. The IJ was removed on [DATE] at 6:26 p.m., after the team, while onsite, verified the POA was implemented via observation, interview, and record review. Findings: a. During a review of Resident 58's Admission Record (Face Sheet) indicated the Resident 58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), chronic [CONDITION(S)] (a syndrome in which the respiratory system fails in proper gas exchange function), chronic obstructive pulmonary disease [([CONDITION(S)]) a chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs], and disorganized [CONDITION(S)] (disorganized behavior and speech that includes disturbance in emotional expression with hallucinations, delusions, with characteristics of distorted thinking or altered perceptions of reality). During a review of Resident 58's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated [DATE], indicated Resident 58 had mild memory problems but could make needs known understood others. According to the MDS, Resident 58 required supervision during the meal and required a mechanically altered therapeutic diet. During a review of Resident 58's untitled care plan, initiated on [DATE], and revised on [DATE], indicated the resident had an episode of suddenly gasping for air related to choking episode while eating a cheese sandwich, eating too fast, gobbling food in one bite, shoving food in the mouth, screams for food, had a poor safety awareness, and had no teeth. This care plan goal for Resident 58 was to remain free from complications of aspiration and not to have choking episodes daily until the next review date on [DATE]. This plan of care interventions included for the resident to have a dental consultation with a follow-up, diet downgraded on [DATE], encourage Resident 58 to take small bites, liquids after solids, chin tuck (position used to delayed swallowing reflexes) for eating, keep in the upright position during eating, follow-up for speech therapy evaluation on [DATE] and ST to monitor during mealtime as needed. Per this care plan, the staff's intervention included to initiate the [MEDICATION(S)] maneuver (procedure for dislodging an obstructed item from a person's windpipe using strong abdominal thrusts to expel air from the lungs) and call 911 emergency services. During a review of Resident 58's clinical records indicated no care plan to address Resident 58's risk for aspiration related to dysphagia and behavior of taking other residents' food. During a review of Resident 58's Order Summary Report for [DATE], the report indicated a physician order, dated [DATE], for a diet of consistent carbohydrates for dysphagia with advanced texture and thin liquids consistency. During a review of Resident 58's NPNs indicated that Resident 58 had two prior choking incidents at the facility on [DATE] and [DATE]. During a review of Resident 58's nursing progress note (NPN), dated [DATE] and timed at 3:03 p.m., indicated the staff reported Resident 58 was choking while sitting on a bench on the patio. According to the NPN, the staff initiated the [MEDICATION(S)] maneuver on Resident 58. A crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was brought, and the staff removed the donut from Resident 58's mouth. A review of the NPN dated [DATE] indicated Resident 58 was given oxygen and could breathe on her own, and a swallow evaluation was ordered. During a review of Resident 58's Interdisciplinary ([IDT] approach with the core team consisting of the resident and various professional team members working toward a common goal for a resident) meeting note, dated [DATE] and timed at 9:49 a.m., the IDT note indicated the IDT met and discussed Resident 58's choking incident. According to this IDT meeting note, staff immediately intervened, performed the [MEDICATION(S)] maneuver, and was able to dislodge the donut from Resident 58's mouth. The IDT recommendations were for staff education on safety, supervision of Resident 58 during meals, and the resident to have a swallowing evaluation. During a review of Resident 58's NPN, dated [DATE] and timed at 10:38 p.m., the NPN indicated Resident 58 had a second choking episode while eating a sandwich and was gasping for air. This NPN indicated the staff immediately paged code blue (a quick way to tell the staff a resident is experiencing a life-threatening medical emergency) and called 911. According to this NPN, the staff initiated the [MEDICATION(S)] maneuvers immediately, and Resident 58 could cough out the sandwich. The NPN indicated Resident 58 was transferred to a general acute care hospital (GACH) via 911 emergency services. During a review of Resident 58's rehabilitation speech therapy (ST) screening, dated [DATE], the ST screening indicated a ST rehab referral was made due to Resident 58's choking incident. The ST rehab screening indicated a change in Resident 58's swallowing status, which required a dysphagia evaluation. Resident 58 required a speech evaluation warranted to assess and determine the least restrictive diet to reduce the risk for future choking or aspiration incidents. During a review of Resident 58's IDT meeting note, dated [DATE] and timed at 10:26 a.m., indicated the IDT met and discussed Resident 58 choking on a cheese sandwich on [DATE]. According to the IDT meeting note, the staff immediately intervened and performed the [MEDICATION(S)] maneuver, and removed cheese sandwich particles from Resident 58's mouth. Resident 58 was transported to GACH. The IDT recommendations included follow-up with a speech evaluation, downgrade diet, and encouraging Resident 58 to take a small bite. During a review of Resident 58's Rehabilitation (rehab) Evaluation and Plan of Treatment, dated [DATE], indicated a referral was made for the evaluation due to dysphagia and choking incidents. A review of the rehab evaluation indicated Resident 58 had a swallowing dysfunction for feeding due to agitation, confusion, and aspiration risk. The rehab evaluation recommendations included a mechanical soft texture diet (foods that can be easier to chew and swallow), thin liquids, and close supervision for all oral intakes. During a review of Resident 58's late entry (L/E) NPN, dated [DATE] and timed at 3:55 p.m., indicated a Certified Nursing Assistant 1 (CNA 1) reported to Licensed Vocational Nurse (LVN 12) on [DATE] Resident 58 was choking once outside on the patio. The NPN indicated LVN 12 went to check on Resident 58 and saw the resident in a wheelchair while the staff attempted to perform the [MEDICATION(S)] maneuver. The NPN indicated Resident 58's was slumped (sit, lean, or fall heavily and limply, especially with a bent back) down, and the resident was not responding to verbal or tactile (touch) stimuli. The L/E NPN indicated Resident 58's mouth was examined, and there were no food particles found. The staff wheeled Resident 58 back to her room and placed Resident 58 on the bed and an assessment was done and indicated Resident 58 was not breathing and had no carotid pulse (pulse felt over the carotid artery on the neck). Resident 58 was placed on the floor, and cardiopulmonary resuscitation ([CPR], an emergency life-saving procedure that is done when a person stops breathing or heartbeat has stopped) was initiated. The NPN indicated a code blue, and 911 was called. According to the NPN, at 8:25 p.m.) the paramedics arrived and took over CPR until 9:13 p.m. Resident 58 expired on [DATE], and the family and physician were informed. During a review of Resident 58's Death Record, dated [DATE], the record indicated Resident 58's body was released to the mortuary at 9:30 p.m. During an interview on [DATE] at 12:44 p.m., the speech language pathologist ([SLP] work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing .) stated Resident 58 required controlled feeding strategies due to having dysphagia. The SLP stated Resident 58 needed more awareness for eating slower and alternate liquids with solids to clear her oral cavity, so there was no food pocketing (keeping some food in the cheeks or back of the mouth rather than swallowing entirely). The SLP stated a care plan for Resident 58's eating fast and gobbling down food was created, but there was no care plan for aspiration related to dysphagia. The SLP stated Resident 58 should have had a care plan to address her dysphagia and the risk for aspiration. During an interview on [DATE] at 4:46 p.m., Licensed Vocational Nurse 12 (LVN 12) stated he was at the nursing station and overheard a staff member call out yelling Resident 58 was choking on the patio. LVN 12 stated he ran out and saw Resident 58 in her wheelchair and saw CNA 1 doing the [MEDICATION(S)] maneuver. LVN 12 stated he asked what happened and was told Resident 58 was choking on food. LVN 12 stated Resident 58 was not breathing, and her head was hanging over with her eyes partially open. LVN 12 stated he checked the resident's mouth and did a finger sweep, and there was no food. LVN 12 stated he, with other staff members, wheeled Resident 58 to her room. LVN 12 stated Resident 58 was transferred to the bed to start CPR. LVN 12 stated code blue was called, and other staff members brought the crash cart. LVN 12 stated he continued to the [MEDICATION(S)] maneuver and removed particles of chewed bread after doing another finger sweep of Resident 58's mouth. LVN 12 stated Resident 58's mouth was checked again, and her mouth was clear. LVN 12 stated they placed Resident 58 on the floor with a backboard after she had no carotid (neck) pulse and started CPR. LVN 12 stated Resident 58 had a physician's order for an advanced dysphagia diet. LVN 12 stated Resident 58 was always hungry, and she would bang on the glass window at the nurses' station while constantly yelling, Where is my food? LVN 12 stated the residents are offered snacks before the cigarette break at 8:30 p.m. LVN 12 stated he does not know where Resident 58 got the peanut butter sandwich. During an interview on [DATE] at 5:08 p.m., Registered Nurse 1 (RN 1) stated she responded to the code blue right away and went to Resident 58's room. RN 1 stated she called 911 while the other staff was performed CPR on Resident 58. RN 1 stated she has worked with Resident 58 and knew Resident 58 had dysphagia and had choked before on a cheese sandwich. RN 1 stated Resident 58 grabbed another resident's cheese sandwich and choked while eating the sandwich. RN 1 stated Resident 58 likes to eat a lot. RN 1 stated the snacks are labeled for special diets. RN 1 stated Resident 58 receives a pudding, and soft bread with peanut butter filling cut into pieces. RN 1 stated a staff member distributes the food snacks for the residents on special diets. RN 1 stated a care plan should have been created to address Resident 58's behaviors of stealing food from other residents due to Resident 58 having two other choking incidents in the past. During an interview on [DATE] at 5:21 p.m., the Kitchen Manager (KM) stated the special diet snacks are labeled for each resident with their name, and the snack choices vary daily. During an interview on [DATE] at 9:17 a.m., the KM stated the kitchen typically serves snacks listed in the Diet and Nutrition Care Manual, including for Resident 58. The KM stated Resident 58's choices included gelatin, pudding, or yogurt for a snack. The KM stated Resident 58 should have never had a sandwich because the item was not listed on her diet ticket, as it was not a part of Resident 58's advanced dysphagia diet. During an interview on [DATE] at 10:57 a.m., the Speech-Language Pathologist (SLP) stated she did not know of Resident 58's behaviors of stealing food from other residents. Still, she was aware of Residents 58's behaviors of eating her food quickly. The SLP stated Resident 58 was on an advanced dysphagia diet and had difficulty eating and swallowing because she had observed Resident 58 at mealtime. The SLP stated she had not evaluated Resident 58 for a swallow evaluation and acknowledged Resident 58 should have received a recent swallow evaluation. The SLP stated the standard of practice for evaluation was quarterly for residents with dysphagia. The SLP reviewed Resident 58's most recent swallow evaluation and stated it was over 11 months ago, on [DATE]. During an interview on [DATE] at 1:39 p.m., CNA 1 stated he had known Resident 58 since 2017 and remembered the resident because he performed the [MEDICATION(S)] maneuver in 2017 when Resident 58 choked on a donut. CNA 1 stated Resident 58 has a behavior of stealing food from other residents, and the resident stole a donut and choked on it. CNA 1 stated they would place Resident 58 separately at another table from other residents because she would grab their food and eat the food very fast. CNA 1 stated that on the night of [DATE], Resident 58 followed him to the patio in her wheelchair and gave her the evening snack. CNA 1 stated he gave Resident 58 a pudding, yogurt, and milk for her snack. CNA 1 stated Resident 58 was supposed to be closely supervised while eating and during the smoking break because she would take food or cigarettes from other residents. CNA 1 stated he went inside the facility to get the cigarette cart and returned to the patio and saw Resident 58 choking. He immediately started to perform the [MEDICATION(S)] maneuver on the resident. (According to the facility's surveillance video, the residents [approximately ,d+[DATE] residents] were left unsupervised in the patio at that time). CNA 1 stated he sent another staff member to get the charge nurse (LVN 12). CNA 1 stated he did not give Resident 58 a sandwich and was unsure where Resident 58 got the sandwich. b. A review of Resident 195's Admission Record (face sheet) indicated Resident 195 was admitted to the facility on [DATE] with diagnoses including Gastroesophageal reflux disease ([GERD]) occurs when stomach acid frequently flows back into the tube connecting the mouth and stomach), dysphagia, major depressive disorder ([MDD] a common but serious mood disorder; causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working), [CONDITION(S)] (a chronic and severe mental disorder that affects how the person thinks feels, and behaves), and dementia (memory loss). During a review of Resident 195's MDS, dated [DATE], indicated Resident 195's cognition ability for daily decision-making was intact. The MDS indicated Resident 195 required supervision (oversight, encouragement, or cueing) while eating. During a review of Resident 195's physician's order, dated [DATE], indicated that Resident 195 had an order for advanced dysphagia texture (nearly a regular diet, but avoid hard, sticky, or crunchy foods; foods should be foods bite-size) diet, large portions, and thin liquids consistency. During a review of Resident 195's NPN, dated [DATE] and untimed, the NPN indicated Resident 195 required supervision and set-up help while eating. During a concurrent observation and interview on [DATE] at 1:46 p.m., Resident 195 was lying flat in the bed, with the bedside table over his chest, eating an advanced dysphagia diet Resident 195 had light brown fluid on his shirt from his neck to his abdomen. There was no staff assisting Resident 195 to eat or elevate his head of the bed (HOB) while eating food in his room. Resident 195 stated his shirt was wet because he spilled his coffee while trying to drink it. Resident 195 stated the staff usually drops off his meal tray and leaves the room. Resident 195 stated he was not able to eat his food well, lying flat in bed. Resident 195 stated no staff offered to elevate the HOB so he could eat safely. Resident 195 stated the staff rarely helps him with his meal or anything and stated, It makes me feel invisible. The resident bed's crank, used to elevate the HOB, was at the foot of the bed, and Resident 195 could not reach it. Resident 195 stated if he could reach it, he would raise himself. During a concurrent observation and interview, on [DATE] at 1:50 p.m., CNA 2 entered Resident 195's room and removed Resident 122's meal tray. Resident 122 was Resident 195's roommate. CNA 2 looked at Resident 195 and did not assist Resident 195 with his positioning or tray and exited the room. CNA 2 stated Resident 195 could eat on his own but stated it was unsafe for Resident 195 to eat while lying in bed flat because he could choke. CNA 2 stated was never told to help Resident 195 in eating. CNA 2 stated it looked like Resident 195 did need help because his shirt was wet, and he could barely see his plate. CNA 2 stated, I should have helped Resident 195 by raising the head of the bed and providing a new shirt or towel. During a concurrent observation and interview, on [DATE] at 2:08 p.m., LVN 10 stated Resident 195 was eating while lying flat in bed. LVN 10 stated CNA 2 provided the meal tray to Resident 195 and should have ensured the resident was safe for eating. LVN 10 stated CNA 2 was supposed to assist Resident 195 during meals. LVN 10 stated Resident 195 was on an advanced dysphagia diet, and eating while lying flat placed the resident at high risk for choking. LVN 2 stated Resident 195 could not raise the head of his bed on his own and needed assistance from staff. During an interview on [DATE] at 8:59 a.m., the SLP stated all residents' HOB must be elevated at 90 degrees while eating unless contraindicated. The SLP stated that Resident 195 was a self-feeder, needed occasional supervision while eating, and needed to have HOB elevated. SLP stated that if HOB did not elevate, the resident would be placed at risk for aspiration due to swallowing being impacted while lying flat. During an interview on [DATE] at 9:39 a.m., the DON stated all staff were educated on safety and elevating the residents' heads of bed while eating, which was fundamental in safety. The DON stated improper positioning during meals placed the resident at risk for choking and aspiration. During a review of the facility's policy and procedure (P/P), revised ,d+[DATE] and titled Resident Care, Routine, indicated it was the P/P of the facility that basic nursing care tasks will be provided for each resident based on resident needs. These tasks are associated with the resident's cleanliness, routine activities of daily living, nutrition, elimination, comfort, activity, rest, and sleep. According to the P/P, these nursing activities may be modified to suit each resident's preferences and individual needs. Encourage residents to take meals in the dining room to promote an increased meal intake, socialization, and increased enjoyment of mealtimes. Provide residents with positioning devices and protective devices, as needed. Nursing staff shall check during each shift for the presence and appropriate use of such devices. Note: All nursing managers, supervisors, and charge nurses are expected to ascertain that all the above care activities occur routinely. It is the responsibility of all nursing staff to maintain the care standards of the facility and assist residents in attaining or maintaining their highest practicable level of functioning. c. During an observation on [DATE] at 1:05 p.m., Resident 88 was observed sitting on the edge of the bed with the meal tray on the bedside nightstand, eating honey garlic shrimp and rice pilaf. Resident 88's meal ticket slip indicated a consistent carbohydrate diet [(CCD) controlled sugar intake for diabetics) that belonged to another resident (Resident 218). During a review of Resident 88's Admission Record (face sheet), the face sheet indicated Resident 88 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 88's diagnoses included dysphagia (difficulty swallowing), Type II diabetes (abnormal blood sugar), contracture (permanent shortening of muscle, tendon, or scar tissue producing deformity or distortion) to the left hand, GERD, and [CONDITION(S)] disorder (chronic mental health condition characterized by hallucinations or delusions [apparent perception of something, not present]). During a review of Resident 88's MDS, dated [DATE], the MDS indicated the resident was severely impaired in cognitive (thought process) skills for daily decision-making, had impaired vision, and required supervision with eating. During a review of Resident 88's physician order, dated [DATE], the order indicated for a controlled carbohydrate dysphagia (CCD) advanced diet. During a concurrent observation and interview, on [DATE] at 1:10 p.m., LVN 11 stated Resident 88 was supposed to receive a CCD dysphagia advanced diet. LVN 11 stated Resident 88 was eating a CCD diet meal but with regular consistency. LVN 11 validated that the meal ticket slip indicated the meal tray belonged to Resident 218, Resident 88's roommate. LVN 11 stated Resident 88 was on a special diet because he had missing teeth and difficulty swallowing. LVN 11 stated Resident 88 was a risk for choking and aspiration. LVN 11 stated it was his responsibility to compare the meal tray with the physician's order before allowing a CNA to serve the resident his meal tray. LVN 11 admitted he did not check meal trays for diet appropriateness before CNAs distributed the meal trays to the residents. A review of Resident 88's plan of care dental complications and missing teeth revised on [DATE] indicate the staff's interventions included providing supervision and monitoring the resident's tolerance to diet texture. During an interview with the SLP on [DATE] at 8:59 a.m., the SLP stated Resident 88 had impaired swallowing and required focused chewing to help to ensure the safe swallowing of food. During an interview on [DATE] at 1:58 p.m., the registered dietitian ([RD] a health professional with special training in diet and nutrition to keep the body healthy) stated that the advanced dysphagia diet is a special textured diet consisting of ground meat or chopped meat and cooked vegetables. The RD stated residents on a special diet needed to receive the correct meal tray, and if a resident received the wrong tray, there was a risk of choking and aspiration. During an interview on [DATE] at 9:37 a.m., the DON stated the nursing staff's responsibility to ensure residents receive the correct meal tray. The DON stated that the licensed nurse was required to check the diet list against the meal tray before receiving it to ensure the correct diet meal was served. The DON stated it was the licensed nurses' duty to ensure safety during mealtimes. The DON stated it was unacceptable to receive the wrong tray and wrong food consistency, which placed the resident at risk for choking and aspiration. During a review of the facility's P/P, revised ,d+[DATE] and titled Therapeutic Diets, the P/P indicated all residents have a diet order, including regular, therapeutic, and texture modification the attending physician prescribes that. According to the P/P, a Therapeutic diet was defined as a diet ordered by a physician or delegated registered or licensed dietitian as part of treating a disease or clinical condition. The purpose of a therapeutic diet is to eliminate or decrease specific nutrients in the diet (e.g., sodium), or to increase specific nutrients in the diet (e.g., potassium), or to provide food that a resident can eat (e.g., mechanically altered diet.). The P/P indicated the licensed nurse accepts the diet order from the authorized prescriber. The licensed nurse completes and signs the Diet Requisition Form, including the full diet order, food allergies, and specific food preference requests. Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care. d. During a review of Resident 30's Admission Record indicated Resident 30 was admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including diabetes mellitus Type 2 (abnormal blood sugar), dysphagia (difficulty swallowing), psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and dementia (memory loss). During a review of Resident 30's Order Summary Report indicated the order to monitor Resident 30 for taking food from other residents' trays. During a review of Resident 30's history and physical (H/P) indicated Resident 30 could not make decisions. During a review of Resident 30's p[TRUNCATED]

Based on interview and record review, the facility failed to ensure the nursing staff properly assessed and identified pressure ulcers (injury to the skin primarily caused by prolonged pressure on the skin) and deep tissue pressure injuries (serious type of pressure injury that begins in the muscle closest to the bone and may not be visible in its early stages) for one of three sampled residents (Resident A). Resident A was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On admission to the GACH, Resident A was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident A developing skin breakdown as a result of the resident's skin not being properly monitored/assessed. Findings: During a review of Resident A's Admission Records, the Admission Record indicated Resident A was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident A had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident A's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/11/2021, the MDS indicated Resident A's cognitive (thought process) skills for daily decision-making were severely impaired. According to the MDS, Resident A required extensive one-person physical assist to complete activities of daily living ([ADLs] tasks such as eating, bathing, dressing, grooming and toileting), bed mobility and transfers. Resident A was totally dependent on the facility's staff for bathing and was incontinent (involuntary voiding of urine and stool) in both bowel and bladder functions. Resident A was assessed at risk of developing pressures ulcers (injury to the skin primarily caused by prolonged pressure on the skin)/injuries but had no skin break down. During a review of Resident A's Braden Scale for Predicting Pressure Sore Risk dated 4/11/2021, the Braden Scale indicated Resident A scored 13 which specified a moderate (average) risk for developing pressure sores. During a review of Resident A's care plan, (untitled) dated 4/24/2020, the care plan indicated Resident A had a higher risk/potential for pressure ulcer development related to (r/t) incontinence. A goal for Resident A was to have intact skin, free of redness, blisters or discoloration. The intervention/task developed included following the facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident A's Treatment Administration Record dated 3/2021 and 4/2021, the Treatment Record indicated Resident A was treated as follows: a. Dilflorasone [MEDICATION(S)] Ointment (used to treat a variety of skin conditions/rashes) 0.05% was applied to Resident A's general body topically (on the skin) one time a day for [CONDITION(S)] (skin irritation) for four weeks on 3/27/2021 through 4/20/2021. b. [MEDICATION(S)] Cream 5% (anti-parasite medication used to treat head lice and scabies) was applied to Resident A from his neck, to his toes topically in the evening every Monday for [CONDITION(S)] for four weeks. It was left on for 12 hours, rinsed and repeated once weekly on 3/29/2021, 4/5/2021, 4/12/2021 and 4/19/2021. During a review of Resident A's Weekly Skin Checks (WSC), dated 3/8/2021, 3/16/2021, 3/23/2021, 3/30/2021, 4/6/2021, 4/13/2021, the WSC indicated Resident A had no pressure sores, only scattered (to chest, bilateral arms and back) redness r/t [CONDITION(S)] (an [CONDITION(S)] skin disease). Further review of Resident A's clinical records indicated there was no weekly skin check for 4/20/2021 available for review. During a review of Resident A's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident's A's GACH Progress Notes (GPN), the GPN dated 4/20/2021 at 23:30 (11:30) p.m., indicated Resident A's skin assessment were as follows: 1. Deep tissue pressure injury (an injury to the underlying tissue below the skin's surface that results from prolonged pressure in an area of the body), right heel, purplish. 2. Deep tissue pressure injury, left heel, purplish discoloration. 3. Stage I (reddened skin with no breaks or tears) lateral (outside) malleolus (ankle) right, right outer foot and right calcaneus (heel) above heel, redness 1.2x1.5 cubic centimeters (cm). 4. Stage I lateral malleolus (bump that protrudes on the outer side of your ankle) right, redness, 1.2x1.5 cm. 5. Stage II (an open wound) Ischium (where the buttocks and leg meet) left, redness with moist scab in center, 1.5x0.5 cm. 6. Stage III (an open wound that is deeper than the second layer of skin) Ischium right, eschar (dark scab) and/or slough (dead tissue separating from living tissue) with [CONDITION(S)] (swelling), 1.3x1.0 cm. During a review of Resident A's GACH Wound Care Consult, dated 4/21/2021, the Wound Care Consult indicated skin assessments as follows: 1. Right scapula (shoulder) Stage II pressure injury, present on admit, wound bed pink, scant serous (fluid) exudate (fluid moving to the site of an injury as part of the healing process), 1.5x0.05x0.1 cm. 2. Right buttock Stage III pressure injury, present on admit, pale, scant serous exudate, 1.0x1.0x0.1 cm. 3. Bilateral heels blanchable (the color goes away by pressing on the site) redness. 4. Bilateral lateral feet blanchable redness. During a telephone interview on 6/23/2021 at 8:36 a.m. with the Director of Nursing (DON), the DON stated weekly skin assessments for residents with wounds were completed by the treatment nurse and for residents without wounds the weekly skin assessments were completed by the charge nurse. During a telephone interview on 6/23/2021 at 9:10 a.m., and a subsequent interview at 12 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated his primary job function was passing medication but the facility needed him to cover as the treatment nurse while the regular treatment nurse was on leave. LVN 1 stated the regular treatment nurse (LVN 2) instructed and observed him for approximately two days in 2019 prior to him actually doing wound treatments. LVN 1 stated he conducted treatment to Resident A's skin according to the physician's treatment order. LVN 1 stated he did not conduct a weekly head to toe skin assessment of Resident A's skin. LVN 1 stated he did not notice if Resident A had any other skin issues besides the rash he (LVN 1) was treating. LVN 1 stated no one reported to him that Resident A had any other wounds. During a review of the facility's undated policy and procedure (P/P) titled, Skin Assessment, the P/P indicated a skin evaluation will be performed on the date of admission and at the following intervals: non-emergent discharge and weekly skin checks and licensed nurse's weekly summary.

Based on interview and record review, the facility failed to provide the necessary pressure ulcer (injury to the skin and underlying tissue that results from prolonged pressure on the skin) treatment, care and services, as per the facility's policy and procedure for one of 14 sampled residents (Resident 5) which included: 1. Providing wound care treatments to Resident 5's left great toe (LGT) pressure ulcer as prescribed by the physician. Resident 5's LGT pressure ulcer was not being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Implementing interventions by monitoring and assessing Resident 5's pressure ulcer on the LGT for signs and symptoms of infection (invasion and growth of germs in the body), as per the resident's plan of care titled Left Great Toe Deep Pressure Injury. 3. Prevent delay in care and treatment when Resident 5's pressure ulcer on the LGT was worsening by notifying the physician of Resident 5's change in wound (pressure ulcer) condition on the LGT in a timely manner (as soon as possible). This deficient practice resulted in Resident 5's LGT wound to worsen to an unstageable pressure ulcer (full thickness tissue loss in which the depth of the ulcer is completely obscured by slough [harbors pathogenic organisms, increases the risk of infection, and impedes healing] and eschar [dead tissue that sheds or falls off from the skin; commonly seen in pressure ulcer wounds usually tan, brown or black in color] in the wound bed) and requiring a transfer to a general acute care hospital (GACH). Resident 5 had an amputation (a type of disfigurement by surgically cutting off a limb) of the LGT after being diagnosed with [CONDITION(S)] (inflammation or swelling that resulted from an infection that occurs in a bone). Resident 5 was admitted to GACH for six days. On 7/7/21 at 3:58 p.m. the Administrator (ADM) and the Director of Nursing (DON) were notified of an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for failure of the facility to ensure staff assessed, monitored, conducted a change of condition assessment and notified the physician in a timely manner when Resident 5's pressure ulcer on the LGT was not improving. The facility's Plan of Action (POA) to remove the IJ situation included the following: The Treatment Nurse, who is a licensed vocational nurse (LVN), completed a full skin assessment of the affected patient (Resident 5) on 7/7/2021 with no additional findings. On 7/5/2021, the Skilled Wound Care doctor rounded with the same LVN Treatment Nurse for evaluation of the left second toe scab. The left second toe wound was categorized as vascular secondary to peripheral vascular disease (reduced blood circulation to a body part other than the brain or heart), there were no new findings and the previous [MEDICATION(S)] (a medication applied on the surface of the body to prevent infection) treatment plan was continued. A review of The Braden Scale (a tool to measure the risk for pressure ulcer development) was completed for residents with existing wounds and for new admissions by the Assistant Director of Nursing (ADON) on 7/8/2021. A review of the Braden Scale for all other residents was initiated on 7/9/2021 to be completed as soon as possible. Data from the review will be used to update care plans based on findings. A skin sweep (to checked skin) of all residents was initiated on 7/9/2021 to be completed as soon as possible. Data from the review will be used to update care plans based on findings. The re-education was initiated by the DON and ADON on 7/7/2021. The Licensed Nurses were in serviced on skin integrity and pressure ulcer including Weekly Skin Check, E-interact - changes of condition and treatment, including timely notification of physician and following treatment orders. The education was validated through Question and Answer. The re-education initiated by Director of Staff Developer (DSD) and Infection Control Practitioner (IP) on 7/8/2021. The Certified Nursing Assistant were in serviced on skin observations during activities of daily living ([ADLs] bed mobility, transferring, bathing, eating, toilet use, dressing and personal hygiene) care, Stop and Watch and Pressure Injury Prevention including turning, repositioning, and reporting. The education was validated through Question and Answer and demonstration return. The Treatment Nurse Competency will be completed by 7/8/2021 by Regional Wound Care Nurse. The weekly wound round will be completed with the Wound Care Doctor and the Treatment Nurses with review the recommendations of wound care by the Skilled Wound Care. The re-education was initiated by the Regional Wound Care Nurse on 7/8/2021. The Treatment Nurses were in serviced on use of PointClickCare (a computer software) Skin and Wound Application for assessment including return demonstration. The education was validated through Question and Answer and return demonstration. The Weekly Interdisciplinary Team (IDT, team members from different disciplines working collaboratively) skin meeting to be held weekly and weekly IDT skin notes to be completed on residents with wounds. The Registered Dietician will review all residents with wounds and provide appropriate nutritional recommendations. The Treatment Nurses to provide the DON with Weekly Wound Report to ensure pressure ulcer or wound management is followed. The weekly report to include wound (pressure ulcer) changes, findings will be presented to Quality Assurance (QA, a process of identifying and correcting to quality deficiencies in the facility) monthly for evaluation and compliance for 3 months or until substantial compliance is attained. The completion Date is on 10/7/2021. On 7/10/2021 6 p.m., the IJ was lifted after the ADM provided an acceptable POA and the Team verified and confirmed the POA was implemented, while onsite, through observation, interviews, and record review and the ADM was notified. Findings: During a review of Resident 5's Admission Record (Face Sheet), the face sheet indicated Resident 5 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/12/2021, the MDS indicated Resident 5 was severely impaired in cognitive skills (thought process) for daily decision-making and was totally dependent on staff for ADLs. During a review of Resident 5's care plan titled, Left Great Toe (LGT) Deep Pressure Injury, dated 2/6/2020, the care plan indicated the staffs' interventions included to cleanse Resident 5's LGT with normal saline ([NS] solution of a salt or salts), pat dry, apply skin prep (preparation), cover with dry dressing daily for thirty days, monitor and assess for signs and symptoms of infection, and notify the physician of changes. During a review of Resident 5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/10/2020, cleanse LGT wound with NS, pat dry, apply skin preparation daily in morning for 30 days. On 11/12/2020, cleanse LGT unstageable wound with NS, pat dry, apply [MEDICATION(S)] and cover with dry dressing daily for 30 days. During a review of Resident 5's Treatment Administration Record (TAR), for the month 12/2020, the TAR indicated on 12/1/2020 through 12/12/2020, Resident 5's LGT was not treated as prescribed by the physician. During a review of Resident 5 Nurses' Progress Notes (NPN), dated 12/17/2020, the NPN indicated Resident 1's physician was notified of the resident's LGT wound had reopened and a new treatment was prescribed. During a review of Resident 5's Treatment Administration Record (TAR), for the month of December started on 12/18/2020, the TAR indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR had missing signatures to indicate treatment was not done on 12/22/2020, 12/25-12/26/2020, and 12/28/2020. During a review of Resident 5's TAR, for the month of 1/2021, dated 1/1/2021 through 1/18/2021, the TAR indicated the treatment to the LGT was not signed to indicate the treatment was done as prescribed by the physician. The TAR from 1/19/2021 to 1/27/2021 indicated there was no treatment ordered and no ongoing assessment of Resident 5's LGT wound until 1/28/2021 which indicated to cleanse Resident 5's LGT with NS and apply an antibiotic ointment (used to treat infection), cover with dry dressing every day for 30 days. During a review of Resident 5's NPNs, dated 1/26/2021 and 1/27/2021, the NPNs indicated Resident 5's LGT had skin growth (a lump of tissue protruding out from surrounding skin) and LGT swelling with indentation (depression or hollow). There were no documentation Resident 5's physician was notified of these changes, as per the resident's plan of care. During a review of Resident 5's NPN, dated 1/28/2021, the NPN indicated on 1/28/2021 at 11:45 a.m., Resident 5's LGT pressure ulcer wound had worsened and measured 1 centimeter ([cm] a unit of measurement) by 0.5 cm. The NPN indicated Resident 5's LGT was swollen and had increased in size and had drainage (unspecified). The NPN indicated at 12:30 p.m., on 1/28/2021, Resident 5's physician was notified, and orders received to transfer Resident 5 to the GACH. During a review of Resident 5's GACH Emergency Department (ED) note, dated 1/28/2021 and timed at 3:02 p.m., the ED note indicated Resident 5 was admitted into the hospital. The admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 5's GACH report, dated 1/28/2021, the report indicated Resident 5's LGT x-ray (electromagnetic [CONDITION(S)] used to generate images of tissues and structures inside the body) indicated significant soft tissue swelling, angulated and displaced (two ends of the broken bone are at an angle to each other) fracture (broken bones) of the left great toe proximal phalanx (fracture bones that are found at the bottom of the toes). During a review of the GACH's pre (before) operative/post (after) operative note, dated 2/1/2021, the note indicated Resident 5 was diagnosed with [CONDITION(S)] with infection to the left big toe. The note indicated Resident 5 underwent an amputation of the left big toe after x-rays revealed dirty granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and marked destruction of the left big toe. The report indicated Resident 5's LGT was amputated and treated with antibiotics (medications use for bacteria treatment). Resident 5 was discharge from the GACH on 2/3/2021. During an interview on 5/12/2021 at 3:35 p.m., the DON stated Resident 5 was transferred to the GACH on 1/28/2021 due to increased swelling to the LGT pressure ulcer wound with drainage. The DON stated the staff was responsible to document after providing wound treatment as given and by not signing the TAR it was an indication the staff did not do Resident 5's LGT wound treatment. During an interview on 6/21/2021 at 11:20 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 5 did not have any wound treatment done in January 2021. LVN 1 stated the Registered Nurse Supervisor (RNS) was notified of the lack of wound care treatment provided to Resident 5. LVN 1 stated she did not follow-up with Resident 5's physician and/or refer Resident 5 to the wound specialist. During a review of the facility's policy and procedures (P/P) titled, Pressure Ulcer Risk Assessment, revised 11/2012, the P/P indicated if a pressure ulcer were not treated properly when discovered, the wound would quickly increase in size, become painful, worsen and become infected. According to the P/P, routine assessment of the wound had to be conducted at least weekly and documented. The assessment and documentation had to included staff's signature and title and worsening situation reported to nurse supervisor.

Based on observation, interview and record review, the facility failed to ensure one of one resident (Resident 1), who had a history of elopement (leaving unsupervised, undetected without authorization) and was preoccupied in leaving the facility, did not elope, by failing to: 1. Ensure Resident 1, who had a diagnosis that included [CONDITION(S)] (a mental illness causing a break from reality, delusions [beliefs not based in reality], hallucinations [seeing, hearing feeling or smelling something that does not exist]) and was provided with close monitoring and supervision. 2. Ensure the staff was creating a diversional (the act or an instance of diverting or turning aside; deviation; distracts the mind) interventions, as per the resident's plan of care, when Resident 1 was seen pacing, packing her bags, and verbalizing she wanted to leave twice that day (6/1/2021). 3. Ensure the facility's environment was safe and secure to prevent Resident 1 from leaving unnoticed. This deficient practice resulted in Resident 1, who was [CONDITION(S)] (mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion [things not real]) and required supervision to meet her needs, eloping and going missing for 12 days from 6/1/2021 at 11:30 p.m. to 6/13/2021. This had the potential for the resident to suffer mental, physical, psychosocial (relating to the interrelation of social factors and individuals thought and behavior) and medical harm due to being unsupervised and being without her daily significant medications to control the diabetes mellitus ([DM] condition in which the body no longer produces enough insulin [hormone] or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body) and antipsychotic medications to control her mental behaviors. During a facility reported incident (FRI) investigation, on 6/11/2021 at 1:29 p.m., An Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident), was identified and declared under F689 (supervision to prevent accidents). The facility's staff failed to provide close monitoring for Resident 1, who expressed she wanted to leave, and the staff saw Resident 1 packing her bags without the staff intervening. The IJ was called in the presence of the Administrator (ADM), Assistant Administrator (Asst. Admin) and Assistant Director of Nursing (ADON) and notified of the immediate action needed and the seriousness to Resident 1's health and safety. On 6/11/2021 at 7:39 p.m., the facility submitted an acceptable Plan of Action ([POA] to correct the non-compliance) and the IJ was lifted on 6/13/2021 at 1:25 p.m., after the team verified, while onsite, the POA was implemented through observation, interview, and record review as follows: 1. A root cause analysis was conducted on how Resident 1 was able to elope. 2. A 24-hour security was established to monitor the facility premises as of 6/2/2021. A gate and egress (mean of exit) security staff implemented a monitoring plan to ensure all points of exit are secured. Security staff walk the interior and exterior perimeter of the facility and physically check fences and exits, including sending email alerts to the Administrator daily. 3. The Assistant Administrator and Regional Clinical Director (RCD) initiated reeducation on 6/11/2021 for the dietary staff, housekeeping supervisor, maintenance supervisor, central supply clerk, and security staff regarding deliveries and monitoring of egress through the delivery/pick up process. The dietary supervisor initiate in-services on 6/12/2021 to the dietary staff. 4. The ADON initiated reeducation on 6/11/2021 to the nursing staff regarding residents' supervision to prevent, minimize and or reduce the potential for elopement and resident safety. 5. The ADON and the Director of Nursing (DON) initiated reeducation on 6/11/2021 to the nursing staff and to the Department managers on the Quality Circle Rounds (beginning of the day visual inspection within the facility) including observation of doors, screens, and windows to ensure equipment is in good working order. 6. The ADON initiated reeducation on 6/11/2021 regarding reviewing, revising, and updating resident care plans for residents verbalizing or attempting to elope from the facility, ensuring residents are monitored closely and visual checks are enforced, and to initiate a Change of Condition and notify the physician if a resident was exit seeking. 7. The RCD completed an audit of wandering assessments and care plans on 6/11/2021 and residents' wandering assessments. The resident's wandering assessments were discovered as incomplete and were corrected and /or initiated on 6/11/2021 by the MDS coordinator nurse and the RCD. For residents with high-risk assessment results, care plans were audited and or initiated to ensure that appropriate safety interventions were identified and implemented in accordance with the resident's risk-assessment by the RCD and the ADON on 6/12/2021. To ensure monitoring for safety, a list of high-risk residents (score above 10) was provided to staff on 6/12/2021. Resident wander scores: 0-4 low, 5-9 moderate, 10+ high risk. 8. Audits of the facility's window screens were completed on 6/11/2021. The Assistant Maintenance Director will order and purchase screens. Appointments were scheduled for screen replacements or repairs with an outside vendor on 6/14/2021 and 6/15/2021. 9. Signage has been posted at the deliver gates on 6/2/2021 to ensure staff are present during deliveries/pick-ups and do not leave the area in order to monitor the security of the gates through the entire delivery and pick up process. 10. An audit of the integrity of the gates were conducted on 6/2/2021 with the Maintenance Supervisor (MS) to ensure that all gates and fencing are in proper repair. Maintenance staff will be responsible for rounding daily to ensure the gates and fencing are properly secured. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, [CONDITION(S)] ([COPD] a lung disease that causes shortness of breath and coughing) and [CONDITION(S)]. The Face Sheet indicated Resident 1 was under conservatorship (a court appointed person to manage a person finance, medical, and personal affairs). During a review of Resident 1's History and Physical (H/P), dated 5/18/2021, the H/P indicated Resident 1 was admitted from a psychiatrist hospital and had a history of elopement. During a review of Resident 1's Order Summary Report dated 5/12/2021, the Report indicated Resident 1 was an AWOL (absent without official leave, missing) risk. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 5/16/2021, the MDS indicated Resident 1's cognition (thought process) was intact, and required assistance with activities of daily living, such as eating, toileting, and required a one-person assist for personal hygiene and getting dressed. During a review of Resident 1's History and Physical (H/P), dated 5/18/2021, the H/P indicated Resident 1 had a history of elopement. A document titled Wandering Risk Assessment (WRA) dated 5/12/2021, the WRA indicated Resident 1 had a high score of 17 which indicate the resident had a high risk for elopement. The WRA scale was as follow: 0-4 low risk, 5-9 moderate risk, and 10+ was a high risk. During a review Resident 1's physician's orders, dated 5/12/2021, the physician's orders included the following medications: 1. Insulin [MEDICATION(S)] Solution: (a fast-acting medication that enables the body to process blood sugar (BS) inject subcutaneously (into the fat layer under the skin) as per sliding scale (set of instructions for administering insulin dosages based on specific blood glucose readings) before meals and at bedtime for Diabetes Mellitus (DM) with ranges. 2. [MEDICATION(S)] Solution (a long-acting medication that helps the body to process blood sugar), inject 18 units subcutaneously at bedtime for DM. 3. [MEDICATION(S)] Tablet (a medication in tablet form that enables the body to process blood sugar), give 1000 milligrams ([mg] a unit of measurement) by mouth two times a day for DM. 4. [MEDICATION(S)] tablet (an antipsychotic medicine, used to treat [CONDITION(S)]), give 2.5 mg by mouth at in the morning and at bedtime related to [CONDITION(S)] manifested by verbal outbursts. During a review of Resident 1's indicated a physician's order, dated 5/12/2021, to check the resident's blood sugar (measures the amount of sugar in a small sample of blood, which can then be corrected with insulin as prescribed): before meals and at bedtime. During a review of Resident 1's Medication Administration Record (MAR) for the month of 5/2021 and 6/2021 (5/13/2021-6/1/2021), the MARs indicated Resident 1 had the following blood sugar check done four times a day (8:30 a.m., 1:30 p.m., 4:30 p.m., and 9 p.m.) and the results ranged from 98 mg/dl - 300 mg/dl. According to the National Institute of Health ([NIH]: a governmental Public Health Research agency), a normal blood sugar reading taken before a meal range from 70 to 130 mg/dl. During a review of Resident 1's laboratory result report, dated 5/19/2021, the results indicated Resident 1's hemoglobin A1c ([HbA1c] a test measures the average amount of sugar in the blood over the previous three months) was elevated at 8.8 percent (%), which means uncontrolled DM (under 5.7 % is nondiabetic, 6.0-6.9% is controlled diabetes and 7.0-8.9 % is uncontrolled diabetes). During a review of Resident 1's care plan initiated on 5/25/2021, the care plan indicated Resident 1 had a moderate risk for falls and injuries due to poor safety awareness, psychiatric/cognitive conditions and the use of anti-psychotic medications. The staff's interventions included to accommodate and meet resident's needs timely. During a review of Resident 1's care plan initiated 5/26/2021, the care plan indicated Resident 1 was an elopement risk/wanderer as evidenced by history of attempts to leave facility unattended and impaired safety awareness. The staff's interventions included to identify the resident's pattern of wandering and monitor location as indicated, document the wandering behavior, and attempt diversional interventions, and provide frequent visual checks every shift for safety and whereabouts. During a review of Resident 1's care plan initiated 5/26/2021, the care plan indicated Resident 1 had potential to demonstrate angry outburst behaviors related to [CONDITION(S)]. The staff's interventions included to identify key times, circumstances, triggers and what de-escalates the resident. The goal indicated the resident will demonstrate effective coping skills. During an interview on 6/10/2021 at 3:44 p.m., the ADON stated Resident 1 was a high wandering and elopement risk and should have been monitored frequently. The ADON stated a specific care plan for a newly admitted , wandering, and elopement risk resident, such as Resident 1, should have been created to monitor Resident 1 every 15, 30 or 60 minutes, but it was not. During an interview on 6/12/2021 at 2:30 p.m., the DON stated Resident 1's uncontrolled diabetes puts her at risk for Diabetic Ketoacidosis (a serious complication where the body produces excessive blood acids [Acidosis] caused by an overproduction of acid that builds up in the blood) due to not having enough insulin in the body that may result in a coma [a period of prolonged unconsciousness brought on by illness]) and or death as Resident 1 had eloped and whereabouts were unknown. Resident 1 was without her daily prescribed significant medications. During a review of Resident 1's clinical record for the assigned task for the certified nursing assistant (CNA), dated 5/12/2021, the task indicated for the CNA to complete visual checks and location monitoring every two (2) hours for safety. During an interview on 6/22/2021 at 2:02 p.m., CNA 1 (works 7-3p.m.) stated she was assigned to residents in the building Resident 1 was housed. CNA 1 stated the day Resident 1 eloped (6/1/2021) two CNAs had called in sick, so the facility was short-staffed and not all residents were assigned a CNA. During a concurrent interview and review of Resident 1's Task Assignment, on 6/10/2021 at 4:30 p.m., the ADON stated Resident 1 should have been monitored every two hours and documented by the assigned staff in the Tasks section of the electronic medical record (EMR). The ADON stated monitoring included visual checks of the resident's location in the facility. A review of Resident 1's documentation of Tasks for 6/1/2021 (the date Resident 1 eloped) indicated the resident was in her room up to 19:47 p.m. (7:47 p.m.), as that was the last time the staff documented Resident 1's whereabouts. The ADON acknowledged Resident 1 was not being monitored every two hours as indicated on the Task Documentation and should have been. The ADON stated Resident 1's location should have been continuously monitored and documented at regular intervals. During a telephone interview on 6/11/2021 at 3:44 p.m., Resident 1's conservator stated Resident 1 had eloped from the last two facilities she was residing. The conservator stated the last time Resident 1 eloped she was found down unconscious in another city. During an interview on 6/11/2021 at 4:46 p.m., the ADON acknowledged Resident 1 had verbalized twice to staff (unspecific staff) that she wanted to leave the facility on 6/1/2021. The ADON stated if a resident verbalized they wanted to leave the facility, the charge nurse or the CNA should have found out why she wanted to leave, provided reality orientation, call the physician to notify them the resident has verbalized wanting to leave the facility. The ADON stated, on 6/1/2021 at 11:33 p.m., the facility's staff could not locate Resident 1, after a search in the resident's assigned room, throughout the building, the facility's grounds, and the perimeter of the facility. During a concurrent interview and a review of a document titled, Elopement Timeline, dated 6/11/2021 and timed at 10:53 p.m., completed by the Assistant Administrator (AA 2) on 6/12/2021 at 1:08 p.m., AA2 stated the staff (unspecific staff) had reviewed the facility's surveillance video (close watch kept over someone or something: supervision for monitoring of behavior, activities) but had not identified how or when Resident 1 eloped. During a concurrent interview and observation of the facility's surveillance video on 6/12/2021 at 1:15 p.m., with the Maintenance Assistant Supervisor (MAS) the following events on 6/1/2021 were observed: 8 p.m.: Resident 1 was pacing in the hallway outside her room wearing a black dress with flowers and socks. 9:20 p.m.: Resident 1 was observed going into her room. 9:39 p.m.: Resident 1 came out of her room wearing white tennis shoes, and a blue hoodie. 9:47 p.m.: Resident 1 was sitting in the hallway towards the kitchen. 9:49 p.m.: Resident 1 was in the Palm Terrace West hallway sitting on a bench with a black duffel bag. 9:50 p.m.: Resident 1 was still sitting in the hallway, had the duffel bag on the floor and was packing and rearranging items in the duffel bag at the same time a male staff member walked past Resident 1. 9:51 p.m.: Resident 1 continued to pack her bag; two female staff members walked by the resident. 9:54 p.m.: Resident 1 seen in the hallway carrying a white cloth bag, that appeared full. 9:55 p.m.: Resident 1 came out of her room without the white cloth bag and walk through the dining room into the hallway. 9:58 p.m.: The camera facing the outside on the building on the boulevard showed Resident 1 walking past the facility. During an interview on 6/13/2021 at 11:24 a.m., the Administrator and the DON stated the staff should have observed and intervened when they saw Resident 1 sitting in the hallway with her duffel bag. The Administrator stated the facility's staff should, go back to the basics of continuous visual monitoring and documenting, and to intervene if a resident display, or verbalizes wanting to leave the facility unauthorized. During a review of the facility's policy and procedure (P/P), last revised on 11/2012 and titled, Elopement Prevention, the P/P indicated it was the policy of the facility to provide a safe and secure environment and ensure the safety of any resident attempting to elope from the facility. It is the facility policy to identify residents at risk and intervene accordingly and to establish a plan of care when risk factors are present. During a review of the facility's P/P, last revised on 4/2017 and titled, Resident Supervision and Monitoring, the P/P indicated that residents are supervised under normal circumstances to ensure optimal safety and clinical outcome. The resident would be able to move about the center at will except in areas designated Non-Resident Areas for safety reasons. Residents are cued to attend activities as needed. Staff will document the designated supervision times of: a. The location (of the resident). b. The activity of the resident. c. The monitoring staff initials.

Based on observation, interview and record review, the facility failed to protect and follow its policy for Abuse Prohibition and Prevention, and ensure one of three sampled residents (Resident 1) was not physically abused by the Certified Nurse Assistant 1 (CNA 1). CNA 1 was observed grabbing Resident 1 by her left arm and pushing her into the room. Resident 1 tripped on a chair and sustained skin discolorations and skin tears. This failure resulted in Resident 1 feeling afraid, restless, and sustaining multiple skin tears to left arm, hand and fingers, and discoloration to right and left arm, hands, and wrist. Findings: During a review of Resident 1's Face Sheet (Admission Record), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 5/17/18 indicated Resident 1 was able to sometimes make herself understood and sometimes understand others and was moderately impaired in cognitive skills (thought process) for daily decision-making. The MDS indicated Resident 1 required supervision for locomotion off unit (how the resident moves to and returns from off-unit locations), and supervision of one-person physical assist for walking in corridor. During a review of Resident 1's History and Physical (H/P) dated 3/15/18, the H/P indicated Resident 1 had no capacity to make decisions. During a review of Resident 1's care plan titled, Resident has Periods of Forgetfulness, dated 5/24/18, the care plan indicated to allow resident ample time to absorb and responds to information, anticipate needs, monitor/document/report to physician any changes in cognitive function, memory and provide frequent visual checks and talk to resident during provision of care. During a review of Resident 1's physician telephone orders, dated 7/30/18 and timed at 2:41 p.m., the order indicated to cleanse with normal saline (solution of salts), pat dry, apply antibiotic (medication to treat bacteria), and cover with gauze (thin translucent fabric), every day and evening shift for skin tear for two (2) weeks. During a review of Resident 1's Licensed Progress Notes (LPN) dated 7/27/18 and timed at 6:31 p.m., the LPN notes indicated on 7/27/18 at 12:45 p.m., Housekeeping 1 and 2 (HKs 1 and 2) reported witnessing CNA 1 being rough and pushing Resident 1 to her room. During a review of Resident 1's Interdisciplinary Team ([IDT] healthcare providers from different fields who work together toward the same goal to provide the best care for residents) Conference, dated 7/30/18 and timed at 11:27 a.m., the IDT conference indicated HKs 1 and 2 reported on 7/27/18 observing Resident 1 walking around with her gown open from the front. The IDT indicated HK 1 and 2 notified CNA 1 and requested help, who grabbed Resident 1 by her right arm pushed the resident into the room. The IDT indicated upon Resident 1's assessment, the following was observed: 1) One (1) by (x) 1.2 centimeters [cm] units of measurement) purplish discoloration on the right posterior elbow 2) 1 x 1.5 cm purplish discoloration on the right front forearm 3) scattered reddish discoloration on the left back area of the forearm 4) 1 x 1.5 cm right wrist discoloration 5) 2 x 2 cm purplish discoloration on left upper arm front aspect 6) 1 x 1.2 cm purplish discoloration 7) 1 x 0.5 cm reddish discoloration on the knuckle of the left wrist 8) 1 x 0.5 cm reddish discoloration on the base of the left 3rd finger 9) 0.5 x 0.5 cm reddish discoloration on the knuckle of the left 3rd finger The IDT note indicated the abuse allegation was validated based on the two staff eyewitness. During a review of the facility's document titled, Employee Corrective Action Notice, dated 7/27/18, the notice indicated CNA 1 was suspended on 7/27/18 pending investigation. The notice indicated two staff members (HK 1 and 2) reported on 7/26/18 at 6:45 a.m., they witnessed CNA 1 grabbing Resident 1 by the arm and pushing the resident to the room inappropriately. During a review of the facility's Resident Interview, dated 7/27/18 and timed at 3:30 p.m., indicated during the interview, Resident 1 stated a male staff grabbed her by the arm and pushed her. The interview report indicated Resident 1 became restless and wanting to leave after she stated being afraid of the male staff. During an interview on 8/3/18 at 12:30 p.m., HK 1 stated on 7/26/18 at 6:20 a.m., Resident 1 was outside in the patio with no shoes, the adult brief down and her gown rolled up and open. HK 1 stated she took Resident 1 inside the facility and witnessed CNA 1 grabbed the resident by her left arm and take her to the room and a few minutes later, HK 1 heard Resident 1 screaming but was unsure why. HK 1 stated she did not report the incident to her supervisor until the following day on 7/27/18 because she thought the other staff present would report the abuse. During an interview on 8/3/18 at 12:48 p.m., HK 2 stated on 7/26/18 at 7 a.m., she witnessed CNA 1 grabbed Resident 1 by the arm and pushing her into the room. HK 2 stated CNA 1 knew he did something wrong because he was smiling after pushing the resident. HK 2 stated she did not report the incident the same day because she thought the other staff was going to report it. During a review of the facility's video in the presence of staff 1, dated 7/26/18 and timed at 6:08 a.m., Resident 1 was seen walking down the hallway with CNA 1, then CNA 1 is seen grabbing Resident 1 by the left arm and roughly pushing Resident 1 into her room. During a concurrent observation in the patio, of Resident 1 and interview, in the presence of CNA 2 on 8/3/18 at 1: 15 p.m., Resident 1 was observed with a skin discoloration to her left upper arm. Resident 1 stated, The man pushed me, I don't know why he did, yes he did. I am OK now. I don't want to see him again, I am afraid of him, he might hit me again. During an interview on 8/3/18 at 1:50 p.m., Social Services 1 (SS 1) stated she heard about the incident by other staff members. SS 1 stated upon hearing of the incident occurring on 7/26/18, she went to see the video surveillance and was upset after she saw how CNA 1 grabbed Resident 1 and pushed her into the room. SS 1 stated she immediately went to see Resident 1, but Resident 1 started crying and stating the staff pushed her. SS 1 stated she then went to look for CNA 1 to interview him, but he had already been suspended. During an interview on 8/3/18 at 2:50 p.m., CNA 1 stated he lost his patience with Resident 1 because she was always wandering to the patio and removing her clothes. CNA 1 stated he was not aware there was a video surveillance, but he was frustrated with Resident 1. During an interview on 8/17/18 at 12:15 p.m., with the Administrator (ADM) and the Director of Nursing (DON), the ADM stated the facility staff failed to report the incident immediately to the supervisor for further investigation. The ADM stated the staff was supposed to follow the policy and report CNA 1 when he was witnessed pushing Resident 1. During a review of the facility's policy and procedures (P/P) titled, Abuse Prohibition and Prevention, revised 3/2018 indicated the facility prohibited and prevented abuse towards residents. The P/P indicated the residents would not be subject to abuse by anyone including staff. The P/P indicated all mandated reporters would report suspicious of a crime against a resident to the supervisor and administrator.

Based on observation, interview, and record review, the facility failed to implement infection control interventions to prevent and control the spread of Coronavirus ((COVID-19) a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) for 227 of 227 residents in the facility in accordance with the facility's infection control policies and procedures (P/P), Center for Disease Control and Prevention ((CDC) Federal agency responsible for controlling the introduction and spread of infectious diseases, and provides consultation and assistance to other nations and international agencies to assist in improving their disease prevention and control, environmental health, and health promotion activities) guidelines and mitigation plan ((MP) a plan to reduce the spread of infection and loss of life) by failing to ensure the following: 1. Staff wore fitted N95 (respiratory protective device designed to achieve a close facial fit and efficient filtration of airborne particles). 2. Staff were fit tested (test to check whether a respirator properly fits the face with a seal) for the available N95 for the prevention of [MEDICAL CONDITION] infection. 3. Staff were using proper infection control techniques to don (putting on protective gear, clothing, and uniforms) and doff (taking off protective gear, clothing, and uniforms) Personal Protective Equipment ((PPE) facemask, face shield, gloves, gowns) as indicated in the MP and the CDC guidelines. 4. Staff followed handwashing protocol after each contact based on the CDC guidelines and MP. 5. One shower room located in the yellow zone was disinfected after each use. 6. Post infection control signage and provide PPE stations and disposable PPE bins in all yellow zones based on the facility's MP and CDC guidelines. 7. Residents were encouraged to social distance at six feet and wearing a facemask. These deficient practices had the potential to result in the spread of COVID-19 infection throughout the facility of 227 residents and 76 staff members that could potentially lead to serious respiratory illness, hospitalization /or death. On 12/23/2020 at 6:52 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's staff inability to follow and implement infection control protocols to prevent the spread of COVID-19 in the facility by not washing hands, wear fitted N95, don/doff of PPEs, ensuring signage was visible throughout the facility and PPE stations available in the yellow zones. The facility's ADM and DON were notified of the immediacy and seriousness of other residents' and staff members health and safety being threatened for not adhering to infection control protocols. On 12/24/2020 at 7 p.m., the ADM and DON were notified the Plan of Action (POA) that was provided by the facility to correct the deficient practice was approved. On 12/28/2020 at 5:21 p.m., the ADM, Assistant ADM (AADM), DON, Corporate Regional Nurse (CRN), and Infection Preventionist Nurse (IPN) were notified the IJ was lifted after review and on-site verification and confirmation of the POA implementation via observations, interviews, and record review of the following actions for the IJ removal: 1. In-service all staff regarding appropriate application of N95 respirators initiated on 12/23/2020 conducted by the DON. Subsequent education and monitoring will be provided by the Infection Preventionist Nurse (IPN) for three (3) months. 2. In-service all staff regarding appropriate proper donning and doffing PPE, including changing gown, gloves, and face shield was initiated on 12/23/2020 conducted by the DON. Subsequent education and monitoring will be provided by the IPN for 3 months. 3. In-service all staff regarding appropriate PPE utilization in each zoning area of the center initiated on 12/23/2020 conducted by the DON. Subsequent education and monitoring will be provided by the IPN for 3 months. 4. Signage regarding handwashing, PPE use and proper donning and doffing techniques, social distancing, cough/sneeze hygiene and hand washing has been posted in all zones of the facility. 5. In-service all staff regarding infection control policy, signs for donning and doffing, social distancing, handwashing, and zoning was initiated on 12/23/2020 conducted by the DON. Subsequent education and monitoring will be provided by the IPN for 3 months. 6. In-service all staff regarding ensuring only one resident per table, ensure 6 feet distance is kept and face mask was initiated on 12/23/2020 conducted by the DON. Subsequent education and monitoring will be provided by the IPN for 3 months. 7. In-service of all staff regarding ensuring medications and drinking cups are kept in the nurse's station to prevent potential contamination. Education regarding appropriate application of N95 respirators initiated on 12/23/2020 conducted by the DON. Subsequent education and monitoring will be provided by the IPN for 3 months. 8. All staff were Fit tested for N95s on 12/26/2020 and 12/28/2020. 9. The IPN and the medical director will assist with the completion of the facility's assessment for infection control. Findings: On 12/23/2020 at 12:20 p.m., during entrance into the facility, the receptionist was observed handing out white N95 mask to all the employees entering the facility. There were no sanitizing wipes for staff to wipe their face shields (cover that protects the entire face from hazards chemicals splashes or potentially infectious materials). An unidentified staff member was observed wearing an N95 improperly with the bottom strings cut off. On 12/23/2020 at 12:45 p.m., during an interview with the ADM, DON and the IPN, the ADM stated staff were not fit tested for the new white N95 mask that was received from the facility's corporation on 11/2020. The ADM stated the facility's last N95 fit testing was conducted in 3/2020 for a different N95. The ADM stated the facility had 17 residents in the Red Zone (COVID-19 positive), 164 residents in the Yellow Zone (suspected COVID-19 positive) and 46 residents in the Green Zone (non-COVID-19 positive). On 12/23/2020 at 1 p.m., there were 22 residents from the green and yellow zones sitting in the dining room of Palm(NAME)unit not wearing face masks or social distancing. Two of the residents (Residents 2 and 3) were sitting at the same table less than six (6) feet apart not wearing a mask, while Resident 2 was coughing. The staff were not observed offering face mask and/or asking the residents to social distance. On 12/23/2020 at 1:20 p.m., during an observation, the shower stall on the yellow zone, across from the nurse's station near Room A2 (on Palm Terrance) was observed with four wet towels on the floor. There was no soiled linen barrel and/or germicidal wipes (disinfectant wipes) in the area to clean the shower chairs after each use. On 12/23/2020 at 2:10 p.m., during an interview, the maintenance supervisor stated the staff should have informed him they needed germicidal wipes to clean the shower chairs after each use and stated he was not informed. On 12/23/2020 at 2:14 p.m., during an observation, on the Palm Grove unit, there was no posted infection control signage to indicate it was a yellow zone. The yellow zone on Palm(NAME)did not have disposable PPE bins. On 12/23/2020 at 2:20 p.m., during a concurrent observation of the yellow zone an interview, LVN 8 was observed wearing two (2) N95s and not performing correct doffing of gown and gloves by removing his gloves first and then removing the gown by pulling it from the front without washing his hands and potentially contaminating his uniform. LVN 8 stated not being aware he could not wear two (2) N95s at the same time. On 12/23/2020 at 2:40 p.m., during a concurrent observation on Palm(NAME)yellow zone and interview, a resident (Resident 1) was observed grabbing water and medicine cups from unattended medication cart and then stacking them back. LVN 1 stated all nurses were in-charge of ensuring residents did not touch the cups because their hands could be dirty and potentially cause a spread of infection. On 12/23/2020 at 2:52 p.m., during a current observation and interview, Certified Nurse Assistant 1 (CNA 1) was observed exiting residents' rooms from the suspected COVID unit (yellow zone) wearing full PPE (facemask, face shield, gloves, gowns) without washing his hands and going to a shower room across the hallway to pick-up wet towels from the floor and placing them in a soiled linen barrel without using germicidal wipes (disinfectant wipes) in the area to clean the shower chairs after each use. CNA 1 then walked out of the building in full PPE, pushing the soiled linen barrel, returned into the building and entered a different residents' rooms wearing the same PPE without removing his gloves or washing his hands. CNA 1 was observed removing his gloves and then touching the gown from the front with his bare hands and disposing of the gown outside the building. During an interview, CNA 1 stated he was aware he needed to remove his PPE prior to exiting residents' room, wash his hands, and remove his gown but he forgot to do it. CNA 1 stated there was no bin nearby to dispose of the contaminated gown and gloves. CNA 1 stated not removing PPE correctly can cause an exposure to COVID and spread the infection. On 12/23/2020 at 2:53 p.m., during a concurrent observation and interview, Licensed Vocational Nurse 1 (LVN 1) was observed not wearing a face shield while working in the yellow zone. LVN 1 stated she forgot to put her face shield on. On 12/23/2020 at 2:56 p.m., during a concurrent observation and interview, CNA 2 was observed not wearing her N95 properly which had only one string mid-back of the head holding the mask on instead of the two strings on the N95 for a secure fit. CNA 2 stated she had not received in-service regarding the proper use of the N95. On 12/23/2020 at 3:10 p.m., during an interview, the DON stated staff should remove PPE and wash their hands before leaving the residents' rooms. On 12/23/2020 at 5 p.m., during an observation of the COVID unit (Red Zone), there were 16 residents and one licensed nurse with two CNAs caring for 16 total care residents. The staff were wearing white N95 mask that were not fit tested for. On 12/23/2020 at 5:10 p.m., during an observation and interview, LVN 2 was observed wearing a green N95 mask brought from home. LVN 2 stated she was given a white N95 mask given by the facility in 11/2020 and was not fit tested . LVN 2 stated the mask did not have a nose clip and was flimsy (light and easily damaged) and she informed the DON and ADM in 11/2020 that the white N95 mask did not provide protection. LVN 2 stated the DON and ADM refused to provide the staff with N95s that the staff were fit tested for and were more protective. LVN 2 stated the facility had a major COVID outbreak a few days after the white N95s mask were provided to all the staff that cause many staff including her to become COVID positive. A review of the white N95 disposable respirator manufactures undated guideline regarding the mask that was being used in the facility by the staff in all the zones, indicated the mask was a universal size that fit most facial shapes. The features included lightweight, thin construction that made it easier to inhale and pull air in (it had filtered holes). The manufacturer's guideline indicated: the mask was not evaluated for antimicrobial (kills or stops the growth of micro-organisms) or [MEDICAL CONDITION] (kills or suppresses viruses) protection. On 12/23/2020 at 5:20 p.m., during an interview, CNA 3 stated she was given the white N95 mask without being fit tested . CNA 3 stated she felt the mask did not provide her the protection she needed to prevent her from acquiring COVID in the facility. CNA 3 stated she tested positive on 11/2020 when the facility had an outbreak few days after receiving the white N95 mask. On 12/23/2020 at 6:18 p.m., during an interview and in the presence of the ADM, the DON stated the staff have not been fit tested for the white N95 mask prior to giving the mask to all facility staff including the staff caring for residents in the yellow and red zones. On 12/24/2020 at 5:55 p.m., during a concurrent interview and review of the white N95 manufactures mask guidelines, the DON stated the label in the box containing the white N95 indicated it was not tested for antimicrobial and [MEDICAL CONDITION] use. The DON stated it was unknown if the mask provided protection against [MEDICAL CONDITION] since the label indicated it had not been evaluated for its use in the COVID suspected zones. On 12/25/2020 at 10:35 a.m., during a concurrent observation and interview, the DON was observed wearing an N95 with both strings cut and tied to be looped around her ears. The DON stated she altered her N95 because her head was hurting and that was why she cut the strings and she was aware that tampering could alter the seal and not protect her from COVID. The DON stated she was not setting a good example to her staff by not wearing her N95 properly. On 12/25/2020 at 10:47 a.m., during an observation and interview, LVN 7 stated the facility did not have PPE carts and disposable PPE bins for all the units in the facility. On 12/25/2020 at 12:01 p.m., during an observation in the red zone and interview, LVN 6 was observed touching her face while removing her white N95. LVN 6 was not observed washing her face or hands after the removal of the white N95. LVN 6 stated she has been working in the Red Zone and she was aware she did not remove the white N95 correctly. On 12/27/20 at 10:05 a.m., during a concurrent observation and interview of Palm Terrance's shower room on the yellow zone, there were three wet towels observed on the floor and no germicidal wipes accessible to clean the shower chairs in between resident's use. During an interview with CNA 2 she stated she did not know why the wet towels were on the shower floor. CNA 2 picked up the wet towels and placed them in a barrel. A review of the facility's policy and procedures (P/P) titled, COVID-19 Extended use of N95 masks, revised 8/26/2020 indicated it was the policy of the facility to prevent unnecessary exposure among residents, healthcare personnel (HCP) and visitors. The P/P indicated the facility utilized the N95 masks to control exposure to COVID-19 when a resident became positive or was suspected. The P/P indicated the facility's staff would be fit tested and trained on the use of the N95 masks and how to conduct a user seal check (procedure conducted by the wearer to determine if the mask was being properly worn and with a good seal). A review of the facility's COVID-19 Mitigation Plan Manual (contingency plan outlines the planning process for identifying and implementing actions to reduce losses) revised on 10/25/2020 indicated residents in the Yellow Zone (suspected COVID) would be restricted to the yellow zone until they have been cleared to enter the Green Zone (COVID free). The Mitigation Plan indicate all staff would wear recommended PPE while in the building per the current Center of Disease Control (CDC) and California Department of Public Health (CDPH) guidance. A review of the CDC COVID-19 guidelines, dated 5/19/2020, provided by the facility, indicated the staff should remove PPEs (doff) by first removing gloves ensuring it does not cause additional contamination, remove gown by reaching up to the shoulders and carefully pulling gown down away from body, rolling it and disposing of the gown and perform hand hygiene. A review of the facility's MP update, dated 12/4/2020 indicated the IP responsibility was to ensure the facility's staff was educated and screened on the infection control guidelines by monitoring and educating staff on infection control practices and ensuring adherence to the CDC and PHN recommended guidelines. The MP indicated the IPN would oversee the training of all staff on the donning and doffing procedures, infection control and infection prevention. The MP indicated the staff would wear the designated PPE while in the building based on the CDC guidance and residents leaving their room will be asked to wear a facemask.

Based on observation, interview, and record review, the facility failed to ensure 2 of 4 sampled residents (Residents 1 and 2) were free from significant medication errors. 1. Resident 1 was found unresponsive (not responded to verbal or physical stimuli), the paramedics transferred Resident 1 to General Acute Care Hospital 1 (GACH 1), where the resident was diagnosed with [REDACTED]. 2. Resident 2 received [MEDICATION NAME] ([MEDICATION NAME], an anti-anxiety medication which acts on the central nervous system to produce a calming effect) without a physician's order. As a result, Resident 1 was hospitalized for [REDACTED]. Findings: 1. A review of the Admission Record (face sheet) indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a standardized assessment and care-planning tool), dated 6/10/18, indicated Resident 1's cognitive skills (ability to think and process information) were severely impaired and the resident needed extensive assistance from staff for toilet use, personal hygiene, and eating. A review of the Prescription General Information from the pharmacy indicated Resident 1 had an order, dated 8/17/15 , for [MEDICATION NAME]/APAP ([MEDICATION NAME] and [MEDICATION NAME], an opioid [MEDICATION NAME] with a fever reducer and pain reliever that used to treat moderate to severe pain), 7.5-325 milligrams (mg), one tablet, as needed (prn) for moderate to severe pain. A review of Resident 1's Medication Regimen Review for the months of 7/2018 and 8/2018 indicated Resident 1 had no physician's order for any narcotic medication. A review of the Nursing Progress Note, dated 8/8/18, indicated Resident 1 was noted with altered level of mental status and a licensed nurse called 911 (emergency call). A review of the facility's Transfer form indicated Resident 1 was transferred to GACH 1 on 8/8/18 at 9:33 a.m. for sudden change in level of consciousness or responsiveness (decreased in level of awareness). A review of Resident 1's Paramedic Report Summary indicated on 8/8/18, the paramedics arrived at Resident 1's bedside at 9:41 a.m. The report indicated Resident 1 was found with abnormal mental status (abnormal state of alertness or awareness), and the paramedics transported Resident 1 to GACH 1. A review of GACH 1 physician's notes indicated Resident 1 arrived at the Emergency Department (ED) on 8/8/18 at 9:51 a.m., with altered level of consciousness (alteration of awareness). Physician 1 ordered one dose of [MEDICATION NAME] ([MEDICATION NAME] - medication to reverse the side effect of opiate overdose) 0.4 milligram per milliliter (mg/ml), injection, at 10 a.m. for over sedation (the administering of a sedative drug to produce a state of calm or sleep), respiratory depression, and/or other signs of opioid overdose to rule out (to eliminate or exclude something) an accidental narcotic overdose. The notes indicated soon after the administration of [MEDICATION NAME], Resident 1 became responsive, and was able make eye contact. Resident 1's breathing and oxygen saturation (the fraction of oxygen-saturated in the blood) were improved. Resident 1's oxygen saturation was improved from the mid to high 80's while on oxygen to 99 percent (%) without oxygen (usually range from 95 to 100 %) At 12 p.m., Resident 1 became slightly less responsive and at 12:07 p.m., MD 1 ordered another dose of [MEDICATION NAME]. Resident 1 became more responsive after the resident received the second dose of [MEDICATION NAME]. The final diagnose was accidental or unintentional opiate or related narcotic overdose. At 2:28 p.m., Resident 1 remained stable for hospital admission. A review of Resident 1's laboratory result from GACH 1 indicated Resident 1's urine was drawn on 8/9/18 at 3 a.m. and the result on 8/10/18 at 7:59 a.m. was positive for opiate. During an interview on 9/25/18 at 2 p.m., LVN 1 stated on 8/8/18, at around breakfast time, Certified Nurse Assistant 1 (CNA 1) told her something was wrong with Resident 1 and CNA 1 asked her to check on Resident 1. LVN 1 stated she called Registered Nurse 1 (RN 1) to assess Resident 1 and she called 911 because Resident 1 was unresponsive. During an interview on 9/25/18 at 2:21 p.m., CNA 1 stated Resident 1 was normally confused, but alert. CNA 1 stated that in the morning of 8/8/18, she called LVN 1 because Resident 1 was sleepy, and she could not wake her up. During an interview on 10/2/18 at 9:50 a.m., RN 1 stated Resident 1 was normally alert, but on 8/8/18, Resident 1 was found drowsy and lethargic (lack of energy). RN 1 stated the paramedics could not wake Resident 1 up that morning. During an interview on 10/4/18 at 2:30 p.m., LVN 2 stated discontinued narcotic are stored in the medication cart, at the back of other controlled drugs. LVN 2 stated it is the practice for nursing staff to use the discontinued narcotic to administer to other residents as long the residents have the physician's order. During an interview on 10/05/18 at 09:42 AM, the DON stated she did not investigate the incident of Resident 1's overdose due to the overdose happened in the hospital. The DON stated she was unable to determine who may have given the medication in error. The DON stated the hospital did the toxicology (detection of poisons) hours after Resident 1 was transferred to GACH 1, and the resident was readmitted to the facility with [DIAGNOSES REDACTED]. During a phone interview on 10/10/18 at 9:02 a.m., Paramedic 1 stated that on 8/8/18 at 9:26 a.m., the paramedic team did not administer medication to Resident 1. During a telephone interview on 10/10/18 at 9:12 a.m., MD 1 stated he had been [MEDICATION NAME] medicine for over [AGE] years, and he was able to recognize what drug overdose looks like. MD 1 stated [MEDICATION NAME] was administered to rule out drug overdose and if Resident 1 was not suffered from a drug overdose, the resident would not respond to [MEDICATION NAME]. MD 1 stated overdosed patients usually require two dosages of [MEDICATION NAME]. On 10/11/18, at 2: 27 p.m., during an interview, Family Member 1 (FM 1) stated he visited Resident 1 with FM 2 on 8/7/18 at 1 p.m., and they stayed at the facility for 30 minutes. FM 1 stated Resident 1 was asleep throughout the visit. A review of the facility's policy and procedure tittle Preparation and General Guidelines, dated 10/2017, indicated medications are administered as prescribed in accordance with good nursing principles and practices. 2. A review of the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician's Order dated 5/1/18 at 4:39 p.m. indicated to administer [MEDICATION NAME] 0.5 mg one tablet by mouth every 12 hours, prn, for anxiety, for 14 days, due to inability to relax and feeling restless. On 5/2/18, the physician ordered to discontinue the above [MEDICATION NAME] order. A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognitive skills were severely impaired and required extensive assistance with a two-person physical assist for transferring, dressing, and toilet use. On 10/5/18 at 11:20 a.m., during an inspection of the medication cart with LVN 4, Resident 2's discontinued [MEDICATION NAME] was stored in the controlled medications drawer behind the current controlled medications. Resident 2's discontinued [MEDICATION NAME] original count was 26 on the Narcotic Count Sheet, but 21 tablets was remained in the bubble pack. A concurrent interview was conducted with LVN 4; she stated the discontinued [MEDICATION NAME] should have been removed from the medication cart and given to the Director of Nurse (DON). On 10/5/18 at 2:03 p.m., during an interview and a concurrent review of Resident 2's Controlled Drug Record sheet, LVN 4 stated 5 tablets of [MEDICATION NAME] were signed out on 5/1/18, at 9 a.m., on 5/11/18 at 9 a.m., on 5/18/18, at 9 a.m., on 5/19/18 at 9 a.m., and on 5/29/18 at 9 p.m. On 10/5/18 at 2:24 p.m., during a review of Resident 2's Medication Administration Record [REDACTED]. A concurrent interview was conducted with LVN 4, she stated empty boxes in the MAR indicated [REDACTED]. On 10/5/18 at 5:20 p.m., during an interview, the DON stated the signed Controlled Drug Record indicated nursing staff administered the medication to Resident 2. The DON stated discontinued narcotic should not be administered to Resident 2, and nursing staff should remove the discontinued medication from the medication cart. A review of the facility's policy and procedure titled, Preparation and General Guidelines, dated 10/2017, indicated, medications are administered in accordance with written orders of the attending physician.

Based on observation, interview, and record review the facility failed, for one of 35 sampled residents (Resident 92) to: 1. Implement the interventions on the plan of care by following the facility's turning schedule, utilizing modalities such as pillows to offload (relive pressure) the bony prominence, and not use a towel in a diaper. Resident 92 developed a pressure ulcer (a wound that occurs due to continued pressure on a bony prominence of the body) on left and right buttocks that increased in size, deteriorated, progressing to left inner buttock and sacrococcyx area (at the bottom of the spine). 2. Implement standard of practice when conducting an assessment upon discovery of an open area to left and right buttocks by not describing the full characteristics of the wound, including the presence of odor, and warmth or boggy ((suspected deep tissue injury) purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue), to ensure implementation of an appropriate treatment and further preventing complications. 3. Implement an appropriate treatment by not using triple antibiotic ointment (a cream containing three antibiotics) on the left and right buttock pressure ulcers, without the presence of an infection to prevent further deterioration and to promote wound healing. These deficient practices resulted in Resident 92's left and right buttocks pressure ulcer progressing from an open area to a Stage III (full thickness tissue loss with fatty layer visible) left inner buttock, and sacrococcyx pressure ulcer, which increased in size, showed slough (yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed), during eight calendar days. Findings: During initial tour on 6/18/2018 at 2:09 p.m., Resident 92 was observed laying on his back, in the bed wearing a diaper with a towel inside the diaper. On the following days, Resident 92 was observed positioned on his back: On 6/19/18 at 8:22 a.m. Resident 92 was observed laying on his back with the head of the bed raised, without use of any pillows to offload the bony prominence (are areas of the body that are at the greatest risk for developing pressure sores resulting in wounds). The turning schedule indicated the resident should had been turned to the left side. On 6/19/18 at 11:18 a.m. Resident 92 was observed laying on his back with the head of the bed raised, without any pillows. The turning schedule indicated the resident should had been turned to the right side. On 6/19/18 at 2:11 p.m. Resident 92 was observed laying on his back with the head of the bed raised, without any pillows. The turning schedule indicated the resident should had been turned to the left side. On 6/20/18 at 8:38 a.m. Resident 92 was observed laying on his back, without any pillows. The turning schedule indicated the resident should had been turned to the left side. A review of the facility's own turning schedule for bed bound residents posted in the classroom indicated the following: 6:00 a.m. - 8:00 a.m. on back 8:00 a.m. - 10:00 a.m. turn left 10:00 a.m. - 12:00 p.m. turn right 12:00 p.m. - 2:00 p.m. turn on back 2:00 p.m. - 4:00 p.m. turn left 4:00 p.m. - 6:00 p.m. turn right 6:00 p.m. - 8:00 p.m. turn on back 8:00 p.m. - 10:00 p.m. turn left 0:00 p.m. - 12:00 a.m. turn right 12:00 a.m. - 2:00 a.m. turn on back 2:00 a.m. - 4:00 a.m. turn left 4:00 a.m. - 6:00 a.m. turn right A review of Resident 92's admission records indicated an admission to the facility on [DATE] and readmission on 8/31/16. Resident 92 was admitted with [DIAGNOSES REDACTED]. disorders, personality changes, and impaired reasoning). A review of Resident 92's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/4/17 indicated Resident 92 was severely impaired with cognitive (ability to think, remember or reason) skills for daily decision making. The MDS assessment indicated Resident 92 was incontinent (no control) of bowel and bladder functions, and required extensive assistance from staff for activities of daily living including toileting, grooming, bathing and eating. A review of the quarterly (once every three months) MDS assessment dated [DATE] indicated the resident was incontinent of bowel and bladder, and at risk for getting pressure ulcers based on a history of acquired pressure ulcers, including the Braden Scale assessment tool (a formal assessment instrument for predicting risk of developing pressure ulcers). A review of the care plan for Resident 92, revised on 10/18/17 indicated the resident was at risk for skin breakdown due to bowel and bladder incontinence. The care plan interventions included to provide extensive assistance to turn/reposition the resident at least every 2 hours, and more often as needed or requested. A review of Resident 92's Braden Scale assessment tool dated 1/18/18, and 4/17/18 indicated a score of 11 to 12 (high risk for pressure ulcer). A review of the Situation, Background, Assessment, Recommendation (SBAR) Communication form, a progress notes for nurses, dated 6/13/18 at 8:30 p.m., indicated there was an open area discovered on Resident 92' left buttock, measuring 2 ((cm) a unit of measurement) by 1 cm, and the right buttock measuring 1 cm by 1 cm. The notes indicated there was no bleeding, and no facial grimacing, indicating there was no pain. However, the notes did not show if the left and right buttock open area was assessed further for differences in skin temperatures, tenderness, skin color, inflammation, and change in tissue consistency (i.e., boggy or firm). The notes did not indicate the reason for the pressure ulcer on the left and right buttocks, and how the possible risk factor were eliminated to reduce further decline. A review of the care plan for Resident 92 dated 6/13/18 indicated a pressure injury Stage III to the sacrococcyx area. The care plan interventions included to call the doctor for any significant changes, and to put the resident on a Low Air Loss mattress ((LAL) an airfilled pressure relieving mattress), and to monitor for signs and symptoms of infection. A review of a physician order [REDACTED]. The order indicated to cleanse the wound with normal saline ((NS) mixture of water and salt for cleaning a wound), pat dry, apply triple antibiotic ointment, and cover with dry dressing (thin loosely woven cloth used to cover wounds). Another order dated 6/13/18 at 10:53 p.m. indicated Resident 92 had a 2 cm by 1 cm open area to the left buttock. The order also indicated to cleanse the wound with normal saline, pat dry, apply triple antibiotic ointment, and cover with dry dressing. According to the John Hopkins Medicine (setting the standard of excellence in medical education, research and clinical care) website, for wound pressure ulcer treatment indicated in order to correctly identify factors to ensure implementation of an appropriate treatment the following should be taken into consideration; · Etiology · Exudates · Odor · Perimeter · Base · Access https://www.hopkinsmedicine.org/gec/series/wound_care.html There was no documented evidence the following factors of considering etiology, exudates, odor, perimeter, base, and access was taken in to consideration prior to determining the use of triple antibiotic ointment on Resident 92's left and right buttocks pressure ulcer. A review of the Nurses Progress Notes dated 6/14/2018 4:59 a.m., indicated Resident 92 was being monitored for the open areas on left and right buttocks. However, the left and right buttock open areas, was not fully described to show a healing or decline. A review of Resident 92's Treatment Administration Records dated 6/1/18 - 6/20/18 indicated the facility carried out the order to the right and left buttock open area. The record indicated to clean the area with normal saline, pat dry, apply triple antibiotic and cover with dry dressing from 6/13/18 to 6/20/18 (8 calendar days). A review of the Nurses Progress Notes dated 6/20/2018 at 4:18 p.m., indicated Resident 92 was examined by the Wound Physician's Assistant (WPA 1) and diagnosed with [REDACTED]. The notes indicated Resident 92's sacrococcyx area was measured at 2 cm by 0.7 cm by 0.1 cm with 20 percent (%) slough and 80 % granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) to be treated with Santyl ointment (enzymatic deriding ointment). The left inner buttock measured at 3 cm by 0.1 cm with 30 % slough and 70 % granulation tissue be treated with Santyl ointment. The notes indicated to use a LAL mattress. A review of the care plan for Resident 92 dated 6/20/18, indicated a pressure injury Stage III and a skin integrity impaired area to the left inner buttock. The care plan interventions listed to assist the resident with turning and repositioning while in bed every 2 hours, and as needed. During an interview on 6/20/18 at 8:29 a.m., about Resident 92 not repositioned according to the facility's turning schedule, Certified Nursing Attendant (CNA 1), responsible for the resident on 7:00 a.m. to 3:00 p.m. shift, stated Resident 92 was not repositioned because of the contractures. CNA 1 stated if turned, the contractures which might cause the resident to fall off the bed. CNA 1 also stated that repositioning the residents can prevent infections and pressure ulcers. During an interview on 6/20/18 at 2:44 p.m., about the towel found Resident 92's diaper, CNA 1 stated the towel kept the resident from playing with himself and getting urine on his chest. CNA 1 stated a wet towel in Resident 92's diaper can cause irritation and infection of the skin. During an interview on 6/20/18 at 3:06 p.m., Licensed Vocational Nurse (LVN 6) stated she had no knowledge of Resident 92 urinating on his chest. LVN 6 stated a towel left on Resident 92's skin could cause skin breakdown, and infection. During an observation of a wound dressing change by LVN 13 on 6/21/18 at 8:56 a.m., Resident 92 had a towel placed as a diaper, and no wound dressing observed on the sacrococcyx wound Stage 3 pressure ulcer. On the same day at 9:11 a.m., LVN 13 stated using a towel as a diaper could irritate or injure the skin, or prevent an existing pressure ulcer from healing. LVN 13 stated staff should immediately report to the treatment nurse or charge nurse if the wound dressing came off, so they could replace it. During a concurrent interview and record review on 6/21/18 at 10:16 a.m., LVN 14 stated Resident 92 should be turned every two hours. LVN 14 stated Resident 92 had a pressure ulcer because of not being turned every 2 hours. During a concurrent interview and record review on 6/21/18 at 1:24 p.m., LVN 13 stated Resident 92 should be turned every 2 hours per care plan dated 10/18/2017 for skin integrity to prevent pressure ulcers, and to promote healing of existing pressure ulcers. During an interview on 6/22/18 at 3:11 p.m., CNA 2 (in charge of the resident on 3:00 p.m. to 11:00 p.m. shift) stated Resident 92 was not repositioned because the legs were contracted, which might cause the resident to fall off the bed. However, CNA 2 acknowledged Resident 92 should get repositioned to prevent pressure ulcer. During an interview on 6/25/18 at 7:24 a.m., the Director of Nursing (DON) stated Resident 92 should be getting repositioned regularly. The DON stated pressure relieving devices and turning every 2 hours are necessary in preventing pressure ulcers. The DON stated using a towel inside or in place of a diaper would keep the skin moist instead of pulling moisture away from the body as a diaper would, which can cause skin breakdown. A review of the facility's policy and procedures titled Pressure Ulcer Risk Assessment revised 11/2012 indicated the most common site of a pressure ulcer is where the bone is near the surface of the body including the backbone and hips. A review of the facility's policy and procedures titled Care for Resident that is High Risk For Skin Breakdown revised 11/2012 indicated to turn and reposition the resident at least every 2 hours using support pillows and cushions to distribute weight. A review of the facility's policy and procedures titled Positioning dated 11/2012 indicated residents are to be moved and positioned as needed to promote comfort, and relive pressure.

Based on observation, interview, and record review, the facility failed to follow a resident's plan of care and its policy on Fall Management, for one of two sampled resident's (Resident 1). Resident 1, who had a history and high risk for falls, had a malfunctioning bed alarm and was not being adequately supervised, resulting in two fall incidents with injuries. This deficient practice resulted in Resident 1 falling on 1/14/18 and 2/28/18, sustaining a [MEDICAL CONDITION] (a deep cut or tear in skin), and head contusion ((bruise), a collection of blood outside of a blood vessel, causing discoloration), which required a transfer to the general acute care hospital (GACH) for head trauma evaluation and laceration repair. On 2/28/18, approximately 45 days later, Resident 1 also sustained a closed head injury with concussion (a [MEDICAL CONDITION] that affects the function of the brain), and loss of consciousness for 30 minutes or less. Findings: A review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED].), [MEDICAL CONDITION] (a progressive disease that destroys memory and other important mental functions), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS), standardized assessment and care screening tool, dated 1/28/18, indicated Resident 1 was not able to report the correct year, month, and day of the week (cognitive impairment). The MDS indicated the resident exhibited verbal behavioral symptoms directed toward others and had the behavior of rejecting care. According to the MDS, Resident 1 required an extensive assistance of a one-person physical assist for dressing, personal hygiene, and toilet use. The MDS indicated Resident 1 used a walker to ambulate, and was unsteady but able to stabilize without staff assistance moving from a seated to standing position and walking. The MDS indicated the resident was frequently incontinent (the inability to control the excretion) of bowel and bladder. A review of Resident 1's Care Plan titled, High Risk for Falls, Related to Poor Safety Awareness, [MEDICAL CONDITION] Drug Use (drugs used to affect the chemicals of the brain and nervous system, used to treat mental illnesses) and Disease Process, date initiated 9/18/14. The staff's interventions included to assess the resident's need for fall intervention such as low bed, bed/chair alarm (devices used to detect movement and sound an alarm if the user tries to get up from the bed or chair on his or her own), padded floor next to bed, and wedge (a cushion used to help prevent wheelchair-bound individuals from sliding forward) in the chair. The Care Plan also indicated for the staff to ensure that the resident was wearing appropriate footwear (well fitted) when ambulating, provide frequently used items within reach, and anticipate and meet the resident's needs and address promptly. A review of Resident 1's Care Plan titled, Resident is on the Prevention Program Falling Star, for History of Falls, initiated on 12/21/16, indicated staff's interventions to educate staff on the need for supervision of resident's whereabouts and activities, and to keep the resident within the staff's view as much as possible. A review of Resident 1's Initial History and Physical (H &P), dated 12/5/17, indicated the resident did not have the capacity to make decisions. A review of Resident 1's Order Summary Report, for the months of 1/2018, 2/2018, and 3/2018, indicated physician's orders [REDACTED]. 1. Carvedilol Tablet (a medication used to treat hypertension and heart failure (a chronic condition in which the heart does not pump blood properly throughout the body), 3.125 milligrams (mg), one tablet twice a day by mouth, for hypertension. Hold medication for pulse rate less than 60 (Normal Reference Range (NRR) is 60 to 100 beats per minute (bpm), or systolic blood pressure (the amount of pressure in the arteries during contraction of the heart muscle) less than 110 (NRR is 90 to 120), ordered 1/19/17. 2. [MEDICATION NAME] Tablet (a medication used to treat hypertension and heart failure), five mg by mouth daily, related to hypertension. 3. [MEDICATION NAME] Tablet (a medication used to treat dementia associated with [MEDICAL CONDITION]), 10 mg by mouth, twice a day, related to dementia, ordered 9/17/14. 4. [MEDICATION NAME] Tablet (a medication used to treat hypertension and chest pain), five mg by mouth daily, related to hypertension. A review of Resident 1's Order Summary Report, for the month of 1/2018, indicated prescribed orders on 1/23/18, to administer [MEDICATION NAME] Tablet (a medication used to treat mental and mood conditions), 100 mg by mouth daily to Resident 1, related to [MEDICAL CONDITION]. The Report indicated prescribed orders on 1/23/18, to administer [MEDICATION NAME] Tablet (a medication used to treat depression), 100 mg by mouth daily to Resident 1, related major [MEDICAL CONDITION]. A review of Resident 1's Order Summary Report, dated 3/1/18, indicated to provide the resident with floor mats for safety precautions, due to multiple falls. A review of Resident 1's Fall Risk Assessment, dated 11/17/17 at 11:17 p.m., and 1/14/18 at 10:37 a.m., indicated Resident 1 was a high risk for falling. The Assessment indicated the resident had a history of [REDACTED]. A review of Resident 1's Progress Note, dated 1/14/18 at 10:30 a.m., indicated at approximately 7:50 a.m., a Registered Nurse (RN) heard a bang and scream. The RN found Resident 1 on the floor, lying on her left side, approximately two feet away from the resident's bed. The Progress Note indicated the resident sustained [REDACTED]. The Progress Note indicated Resident 1 complained of pain, four out of 10 pain (10 being the most severe pain) on the pain numerical scale. According to the Progress Note, Resident 1 was transferred to the GACH for evaluation and treatment of [REDACTED]. A review of Resident 1's Progress Note, dated 1/14/18 at 1:30 p.m., indicated the resident returned from the GACH with two sutures (stitches holding together the edges of a wound or surgical incision) to the laceration on the resident's right side of the forehead. A review of Resident 1's Progress Note, dated 2/18/18 at 11:53 p.m., indicated the resident had a purplish/red skin discoloration to the corner of the resident's left eye. A review of Resident 1's Progress Note, dated 2/28/18 at 1:10 a.m., indicated a Licensed Vocational Nurse (LVN) heard a loud sound from Resident 1's room, and heard the resident crying. The Progress Note indicated the LVN found Resident 1 lying face down next to her bed, with the resident's head toward the foot of the bed. The Progress Note indicated the right side of Resident 1's forehead was bleeding with a large bump, small laceration, and bruising. The Progress Note indicated the resident was unable to state what caused the fall. A review of Resident 1's Progress Note, dated 2/28/18 at 5:55 p.m., indicated the resident returned from the GACH with an abrasion (superficial damage to the skin ) to the left upper back, bruising on the right side of the face around the eye, and a bump to the right side of the forehead with an open wound. A review of Resident 1's Progress Note, dated 3/1/18 at 1:43 a.m., indicated Resident 1 had slight swelling to the entire face. The Progress Note indicated the following fall precautions were in place: the resident's bed was in lowest position, staff performed frequent visuals, and new orders were obtained to apply floor mats as safety precautions (listed on the resident's prior care plans for fall prevention). A review of Resident 1's Progress Note, dated 3/1/18 at 7:47 a.m., indicated Resident 1 had the following injuries: 1. A laceration to the right forehead measuring 1 cm in length and 1 cm in width, with no active bleeding. 2. Purplish/bluish discoloration to the right eye measuring 4 cm in length and 1 cm in width. 3. Purplish/bluish discoloration to the forehead measuring 4 cm in length and 8.5 cm in width. 4. Purplish discoloration to the right side of the face measuring 2 cm in length and 6 cm in width. 5. An abrasion to the resident left mid back area, measuring 2.5 cm in length and 2 cm in width, with no active bleeding. A review of Resident 1's Fall Scene Investigation Report, dated 1/14/18 at 10:38 a.m., indicated factors observed at the time of the fall was environmental factors and the resident's loss of balance. The Report indicated Resident 1 was found barefoot, with no alarm or assistive device used at the time of the unwitnessed fall. The Report indicated the root cause of Resident 1's fall was unknown, and the initial interventions to prevent future falls included the use of bed alarm and floor mat beside the bed. The Interdisciplinary ((IDT), a group of health care professionals working together toward a common goal for the resident) Note for Falls, indicated Resident 1 had risk factors for having fall occurrences, which included: poor safety awareness, poor balance, attempting to be independent beyond ability, behavior, and multiple medications. A review of Resident 1's Emergency/Urgent Care record from the GACH, dated 1/14/18 at 11:26 a.m., indicated the resident fell out of the bed unwitnessed. The record indicated Resident 1 answered questions bizarrely and sustained a 1.5 cm in length laceration to the right forehead. The record indicated Resident 1 had a laceration repair on the right forehead, with two sutures. A review of Resident 1's Fall Scene Investigation Report, dated 2/28/18 at 1:10 a.m., indicated a factor observed at the time of the fall was the Resident slipped. The Report indicated Resident 1 was alone and unattended and was unable to state what caused her to fall and could not provide information on what the resident was doing prior to her fall. The Report indicated Resident 1 did not have an alarm or assistive device used at the time of the unwitnessed fall. The Report indicated the root cause of the fall was unknown, and initial interventions to prevent future falls was to remind the resident to use the call light (a bedside button that when pressed, directs signal to the nursing station, as a means of communication for the resident to his or her care providers), and wait for staff to assist with all transfers. The IDT Fall Investigation Notes indicated Resident 1's blood pressure was elevated with a value of 208/85 millimeter of mercury (mmHg) (NRR is 120/80 mmHg), at the time of the resident's fall. A review of Resident 1's Emergency Department (ED) Provider Note from the GACH records, dated 2/28/18 at 2:51 a.m., indicated the resident sustained [REDACTED]. The ED Note indicated Resident 1 was found face down on the floor, with a one cm laceration and swelling on the right side of the resident's forehead. The ED Note indicated the resident grimaces (a twisted expression on one's face, expressing disapproval, disgust or pain) with touch. The Provider Note indicated Resident 1's wound was copiously (abundantly, in large quantities) irrigated and the edges were approximated (to connect or bring together) together with tissue adhesive. The ED Note indicated Resident 1's final [DIAGNOSES REDACTED]. A review of Resident 1's Rehab Screening, dated 3/1/18 at 5:37 p.m., indicated the Occupational Therapist (OT) saw the resident after having a fall incident. The Screening report indicated Resident 1 exhibited impulsive behavior and tangential (indirect connection or off topic) thinking, and had poor safety awareness. The Screening report indicated No evaluation required, and that the resident would not benefit from skilled rehabilitation, due to impulsive behavior and mental status. The Screening report did not indicate the OT's Observations/Findings of the resident. A review of the facility's Policy and Procedure (P/P) titled, Falls Management, revision dated 11/2012, indicated new or existing residents scoring as high risk would have interventions implemented to reduce the potential for falls outlined in their plan of care. The P/P indicated residents who have sustained a fall, would be placed on the facility's heightened awareness program, which included a visual identifier, designed to alert staff of a resident who has actively fallen in the presence of standard fall prevention interventions that have been outlined in the care plan. The P/P indicated the identifiers would be placed on the nameplate outside the resident's room, and assistive devices used (wheelchair or walker). The P/P indicated resident who have fallen would remain in the program until no further falls for 90 days. The P/P indicated the designated facility Fall Team would review recent falls daily, evaluate the cause, determine additional strategies as needed to prevent recurrence for each resident, and further revise the care plan if needed. On 3/13/18 at 8:50 a.m., during an observation and interview, Resident 1 was observed with redness on her left cheek and maroon discoloration to the resident's right cheek. Resident 1 was observed with a white gauze dressing to the right side of her forehead. Resident 1 stated she fell and hit her forehead on the floor, which caused discoloration on her face. On 3/13/18 at 10:50 a.m., during a telephone interview, Physical Therapist 1 (PT 1), from an adult day care, stated on 2/2018, the resident was found on the floor at the facility, and sustained two black eyes, a welt (a red, swollen mark left on a flesh caused by a low or pressure) on the right side of the resident's forehead covered with a bandage, and bruising around her mouth. On 3/13/18 at 2 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1), stated Resident 1 was frequently incontinent, required assistance to be changed and with personal hygiene. CNA 1 stated Resident 1 did not use her walker at times, and clings to the handrails in the hallway. CNA 1 stated the resident did not usually use the call light for assistance and the resident was at risk for falls due to her confusion, and required frequent monitoring to know the resident's whereabouts. On 3/13/18 at 2:30 p.m., during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was very confused. LVN 1 stated the resident had a pretty ugly fall during LVN 1's shift. LVN 1 stated she heard a loud bang and a distinct crying, and found Resident 1 lying face down on the floor of her room bleeding. LVN 1 stated Resident 1 had blood on her forehead. LVN 1 stated Resident 1 had a bed alarm, but did not remember hearing the alarm make a sound. LVN 1 stated the resident had a hard fall with facial injury, and sustained facial swelling and bruising. LVN 1 stated Resident 1 was a high risk for falls and the roommates of Resident 1 would look out for the resident. LVN 1 stated the resident required frequent visual monitoring. On 3/13/18 at 4:15 p.m., during an observation and interview, LVN 2 stated Resident 1 does not have a bed alarm, and has not seen a bed alarm used for the resident. On 3/13/18 at 4:20 p.m., during an observation and interview, CNA 2 stated Resident 1 had a bed alarm. A white device (push button) connected to a cord was observed hanging from the resident's bed rail to underneath the bed. When Resident 1 stood up from the bed, the resident's bed alarm was observed not making noise. CNA 2 was observed switching the device on. The pad of the resident's bed alarm was observed underneath the resident's mattress and on top of base of the bed frame. CNA 2 was observed maneuvering the pad of the bed alarm. CNA 2 stated that the device was not working, and there could be something wrong with the battery. On 3/13/18 at 4:25 p.m., during an interview and concurrent record review, the Assistant Director of Nursing (ADON) stated the bed alarm should be checked every shift by the CNA, to ensure the alarm was functioning. The ADON stated checking for bed alarm function is not seen on Resident 1's clinical record. The ADON stated Resident 1 attempts to get out of bed unassisted and should have a bed alarm.

Based on observation, interview and record review, the facility failed to ensure residents who were assessed as high risk for developing pressure ulcers (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction), or had a history of [REDACTED]. 1. Perform thorough skin assessments for Resident 1, which included measurements of the resident's wounds upon readmission to the facility, and ensure accurate weekly wound assessments were performed for Resident 1, per facility's policy and procedure. 2. Follow Resident 2's plan of care for staff to provide immediate incontinent care, and avoid the resident's use of incontinent briefs. 3. Reposition Resident 1 and 2 every two hours, per plan of care and physician recommendations. 4. Provide an appropriate setting on the pressure-reducing bed, based on Resident 1's actual weight. 5. Provide wound care treatment for [REDACTED]. (Cross referenced to F 692) These practices resulted in Resident 1 transferring to the general acute care hospital (GACH), for three weeks, due to fever [MEDICAL CONDITION] (a life-threatening complication of an infection). Resident 1 developed multiple new pressure ulcers (a total of 15 pressure ulcers), which included Stage IV pressure ulcers (skin break with deep tissue involvement with necrotic (dead) tissue present) that required debridement (the removal damaged tissue from a wound) of the wounds, and caused existing pressure ulcers to become infected. Resident 2 developed a Stage III pressure ulcer (Full thickness tissue loss, with subcutaneous fat potentially visible) to the right trochanter (hip), from a reopened scab, and developed a Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer, with a red or pink wound bed, and may present as an intact or open blister) to the left hip. Findings: 1. A review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 1 had [DIAGNOSES REDACTED]. (an inherited condition in which nerve cells in the brain break down over time), Stage IV pressure ulcer,[MEDICAL CONDITIONS] (paralysis in all four limbs), contracture (a muscle or tendon that is shortened or tightened to the point it could not stretch normally), cachexia (marked weight loss and muscle loss), and protein-calorie malnutrition. A review of Resident 1's History and Physical (H & P), dated 3/18/18, indicated the resident did not have the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 2/9/18, indicated Resident 1 was not able to report the correct year, month, and day of the week, and rarely had the ability to understand others and make self-understood. According to the MDS, Resident 1 was totally dependent on one person for physical assistance with eating, toilet use, and personal hygiene, and was totally dependent on two or more persons for bed mobility. The MDS indicated Resident 1 was always incontinent (the inability to control urination or defecation) of bowel and bladder, and had impairment to both sides of the upper and lower extremities. The MDS indicated Resident 1 had three unhealed Stage III pressure ulcers, and two unhealed Stage II pressure ulcers present upon admission or reentry to the facility. The MDS indicated Resident 1's largest pressure ulcer was measured at 2.5 centimeters (cm) in length, 2.5 cm in width, and 0.2 cm in depth, and had slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps) present. The MDS indicated treatments included a pressure-reducing device for Resident 1's bed, a turning and repositioning program, and nutrition and hydration intervention to manage the resident's skin problems. A review of the facility's Policy and Procedure titled, Pressure Ulcer Risk Assessment, revised 11/2012, indicated that pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (perspiration, feces, and urine). The policy and procedure indicated for nurses to conduct skin assessments at least weekly to identify changes, and for staff to maintain a Stop and Watch while performing routine skin inspections daily or every other day as needed. The policy and procedure indicated that at-risk residents need to be identified and have interventions implemented promptly, to attempt to prevent pressure ulcers. A review of Resident 1's Care Plan titled, Resident is at Risk for Pressure Injury, Related to Immobility, Incontinence, and Disease Process, date initiated 10/21/17, indicated staff interventions to administer treatment as ordered, and monitor of effectiveness. The Care Plan indicated interventions to assess, record, and monitor wound healing weekly if any present; appearance, color, signs and symptoms of infection, measure wound size (length, width, and depth where possible); stage; assess and document the status of wound perimeter, wound bed and healing process; report improvements and declines to the physician. The Care Plan indicated interventions to monitor the resident's nutritional status; serve diet as ordered; monitor the intake and output. The Care Plan indicated Resident 1 required total assistance and indicated interventions to turn and reposition the resident at least every two hours. A review of Resident 1's Admit/Readmit Assessment, dated 12/26/17 at 10:11 p.m., indicated the resident had a right hip pressure injury DTI ((Deep tissue injury), a pressure-related injury to subcutaneous tissues under intact skin), measured as 2.5 cm in length, 2.5 cm in width, and unstageable (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) and no depth indicated. The assessment indicated Resident 1 had a sacrococcyx (a large triangular bone at the base of the spine down to the tailbone) healing pressure injury, left and right ear pressure injury, and left clavicle open blister. There was no documentation the pressure injuries on the sacrococcyx, left and right ear and left clavicle were measured. A review of Resident 1's Pressure Ulcer Risk Assessment (Braden Scale), dated 3/15/18 at 9:22 p.m., indicated the resident was at very high risk for developing a pressure ulcer. A review of Resident 1's Nurse's Weekly Look Back Summary, dated 12/31/17, 1/14/18, 1/28/18, and 2/18/18, indicated Bilateral heel boots while in bed, every shift for skin breakdown prevention on low air loss mattress (therapeutic alternating pressure mattress with low air loss, and lateral rotation, to prevent and treat pressure ulcers), wears heel boots. Repositioned to relieve pressure and for comfort. There was no documentation of Resident 1's general skin condition that included pressure ulcers. A review of Resident 1's Weekly Skin Check, dated 12/31/17, 1/14/17, and 1/28/18, indicated, On low air loss mattress, wear bilateral heel boots. Repositioned to relieve pressure and for comfort, was documented under Describe skin issues that require follow up. The skin check indicated, Bilateral heel boots while in bed every shift for skin breakdown prevention, was documented under the section of the resident's skin condition, which indicated to document any irregular skin conditions of the resident. A review of Resident 1's Wound Weekly Monitoring/Assessment, indicated the following assessment of Resident 1's pressure ulcers: 1. Left ear pressure ulcer, measured as 1 cm in length, 1 cm in width, 1 cm in depth, and was unstageable on 1/26/18. 2. Right hip trochanter Stage III pressure ulcer, measured as 4.5 cm in length, 4 cm in width, and 0.3 cm in depth on 1/26/18. 3. Left ear Stage IV pressure ulcer, measured as 1 cm in length, 1 cm in width, and 0.5 cm in depth on 2/1/18. 4. Left hip trochanter Stage III pressure ulcer, measured as 2 cm in length, 2 cm in width, and 0.1 cm in depth on 2/1/18. 5. Left clavicle Stage III pressure ulcer, measured as 3 cm in length, 1 cm in width, and 0.1 cm in depth on 2/1/18. 6. Left hand knuckles Stage IV pressure ulcer, measured as 2.5 cm in length, 2.5 cm in width, and 0.2 cm in depth on 2/7/18. 7. Left hand palm pressure ulcer, measured as 3.5 cm in length, 3.5 cm in width, with no depth indicated, and was unstageable on 2/7/18. 8. Left lower jawline pressure ulcer, measured as 2 cm in length, 1 cm in width, and 1 cm in depth on 2/14/18. A review of Resident 1's Wound Weekly Monitoring/Assessment, indicated there was no documentation of Resident 1's pressure ulcers assessed weekly on 12/26/17, 1/2/18, 1/9/18, and 1/16/18 that included the measurements, color of the wound bed, presence of drainage, its color, its amount, and odor. A review of Resident 1's Surgical Consult Progress Note, dated 1/10/18, indicated the resident had the following pressure ulcers: 1. Left ear pressure ulcer, measured as 1 cm in length, 0.2 cm in width, and 0.1 cm in depth. 2. Right ischium (the curved bone forming the base of each half of the pelvis) pressure ulcer, measured as 2.5 cm in length, 1.2 cm in width, and unable to determine depth. 3. Left buttock pressure ulcer, measured as 1 cm in length, 1 cm in width, and unable to determine depth. 4. Sacrococcyx pressure ulcer, measured as 1.2 cm in length, 0.5 cm in width, and unable to determine depth. A review of Resident 1's Surgical Consult Progress Note, dated 1/17/18, indicated the resident had the following pressure ulcers: 1. Left ear pressure ulcer, measured as 1 cm in length, 1 cm in width, and 0.1 cm in depth. The progress note indicated the wound increased in size. 2. Right ischium pressure ulcer, measured as 4.5 cm in length, 4 cm in width, and 0.3 cm depth. The progress note indicated the wound increased in size. 3. Sacrococcyx pressure ulcer, measured as 2 cm in length, 0.5 cm in width, and 0.1 cm in depth. The progress note indicated the wound increased in size. 4. Left proximal hand knuckles of unknown etiology, measured as 1 cm in length, 0.5 cm in width, and unable to determine depth. A review of Resident 1's Nursing Home to Hospital Transfer Form, dated 1/22/18, indicated the resident had a Stage III healing sacrococcyx pressure ulcer, Stage III left and right trochanter pressure ulcer, with scant amount of drainage. A review of Resident 1's Health Status Note, dated 1/22/18 at 11:04 p.m., indicated the resident was readmitted back to the facility. Licensed Vocational Nurse (LVN) 1 documented, Skin warm and dry, skin care rendered, repositioned as tolerated. Continues wound care to site, dressing intact, no bleeding or signs of infection. A review of Resident 1's Surgical Consult Progress Note, dated 1/31/18, indicated the resident had a left lateral neck clavicle pressure ulcer, measured as 3 cm in length, 2 cm in width, and 0.3 cm in depth. The progress note indicated the following wounds were debrided: 1. Left ear pressure ulcer, with a total area of one (1) square (sq) cm of devitalized (weak) tissue. 2. Right ischium pressure ulcer, with a total area of six (6) sq cm of devitalized tissue. 3. Left lateral neck clavicle pressure ulcer, with a total area of six (6) sq cm of devitalized tissue. A review of Resident 1's Telephone Physician Order, dated 2/22/18 at 10:51 a.m., indicated to transfer the resident to the GACH to rule [MEDICAL CONDITION], and to evaluate and treat the resident's fever of 102.1 F ((Fahrenheit), 97.7 F to 99 F), oxygen saturation (the percentage of hemoglobin in the bloodstream occupied by oxygen) of 86 percent (%) (Normal Reference Range (NRR) is 95 to 100 %), wounds on the resident's left clavicle, jawline, and left palm of the hand with foul smelling drainage. A review of Resident 1's Nursing Home to Hospital Transfer Form, dated 2/22/18, indicated there was no documentation of the resident's skin condition under Skin/Wound Care: Pressure Ulcers (Stage, Location, Appearance, Treatments). A review of Resident 1's Emergency Department (ED) notes, from the GACH, dated 2/22/18 at 8:40 p.m., indicated the resident presented as emaciated (excessively thin and wasted) and contracted. Resident 1's tongue is protuberant (bulging) and appears dry. The notes indicated the resident had multiple small open wounds. A review of Resident 1's GACH Records, dated 2/22/18 at 2:04 p.m., indicated the resident had an elevated white blood cell count ((WBC), indicates an infection that the immune system is fighting to destroy) of 16.2 cells per liter (NRR is 4.3 to 10.8 cells per liter). A review of Resident 1's H & P from the GACH, dated 2/23/18 at 2:45 p.m., indicated the resident had a fever of 102.1 F, low oxygen saturation, and yellowish, foul smelling drainage to the left clavicle, left hand, and right trochanter upon admission. The H and P indicated the resident was admitted to the GACH [MEDICAL CONDITION], and multiple Stage IV infected pressure ulcers. The H and P indicated that Resident 1 had a pressure ulcer to the left clavicle area measured as four (4) to five (5) cm with purulent drainage and [DIAGNOSES REDACTED]tous (redness) edge, similar to the right trochanter pressure ulcer. The H and P indicated Resident 1 had purulent drainage or slough with black edges, and surrounding redness around the black edges, measured as 5 cm on the left hand. The H and P indicated the resident had contracture on the wrist, hand, ankle, and bilateral knees, and was lethargic (weariness that involves diminished energy, mental capacity, and motivation) and nonverbal. A review of Resident 1's GACH record, dated 2/23/18, indicated the resident had [MEDICAL CONDITION] (an elevated sodium level due to dehydration or loss of body fluids), with a level of 150 milli equivalent (meq) per liter (L) (NRR is 136 to 146 meq/L). The GACH record also indicated Resident 1 had [MEDICATION NAME] (a low serum [MEDICATION NAME] level, due to the body's inability to properly absorb and digest protein, suggesting malnutrition) of 1.90 (gm) per deciliter (dL) (NRR is 3.40 to 5.00 gm/dL). A review of Resident 1's GACH record, dated 3/8/18, indicated wound education to reposition Resident 1 every two hours or as needed, provide pressure redistribution, offloading, and providing perineal care (peri care is washing the genitals and anal area) after each incontinence. The GACH Record indicated the resident had a surgical debridement on 3/7/18 for the following wounds: 1. Stage IV left third metacarpal (MCP) pressure ulcer, measured as 2 cm in length, 2 cm in width, and 0.3 cm in depth. 2. Stage IV left shoulder pressure ulcer, measured as 2.5 cm in length, 3 cm in width, and 0.7 cm in depth. 3. Stage IV left trochanter pressure ulcer, measured as 3 cm in length, 3 cm in width, and 1 cm in depth. 4. Stage IV right trochanter pressure ulcer, measured as 5 cm in length, 7 cm in width, and 1 cm in depth. 5. Stage IV left clavicle pressure ulcer, measured as 2 cm in length, 5 cm in width, and 0.5 cm in depth. A review of Resident 1's physician progress notes [REDACTED]. 1. On 1/12/18, Resident 1 had a Stage III pressure ulcer in the sacrum (the triangular bone in the lower back situated between the two hipbones of the pelvis), multiple ulcers, and left ear ulcer with drainage. 2. On 2/9/18, Resident 1 had a Stage IV pressure ulcer in the sacrum, black eschar (dead tissue) to the right hand, left clavicle pressure ulcer, and multiple Stage IV pressure ulcers. 3. On 4/2/18, Resident 1 had a right hip ulcer with greenish slough, and [DIAGNOSES REDACTED] edges. The note indicated Resident 1 had multiple Stage IV pressure ulcers. A review of Resident 1's Care Plan titled, Deep Tissue Injury to the Left Hand Side of the Palm, Related to Impaired Bed Mobility and Nutritional Impairment, date initiated 2/15/18, indicated interventions for staff to assist the resident in turning and repositioning while in bed every two hours, and to provide evaluation by the Registered Dietician (RD) as needed. A review of Resident 1's Documentation Survey Report, for (MONTH) (YEAR), indicated to reposition the resident at least every two hours, while in bed or on a wheelchair. The report indicated there was no documentation of the times Resident 1 was repositioned from 3/15/18 to 3/19/18, and 3/28/18 to 3/31/18. A review of Resident 1's Order Summary Report, for (MONTH) (YEAR), indicated enteral feeding (the delivery of a nutritionally complete feed, directly into the stomach and intestine) orders on 3/28/18, to administer [MEDICATION NAME] (fortified therapeutic nutrition that provides complete, balanced nutrition for enteral feeding) 1.5, at 60 milliliters (ml) per hour for 20 hours, to provide 1200 ml per 1800 calories (Kcal). The order indicated to turn on the infusion at 1 p.m., and to turn off infusion at 9 a.m., or until the dosage was met. A review of Resident 1's Order listing Report, order range dated 1/1/16 to 4/30/18, indicated physician orders [REDACTED]. 1. Cleanse with Normal Saline ((NS), a mixture of salt and water), pat dry, apply [MEDICATION NAME] (a wound care dressing used to treat hard to heal wounds and burns), and cover with dry dressing every day shift, for the resident's Stage II pressure ulcer in the back of the resident's right ankle for 30 days. 2. Cleanse with NS, pat dry, apply skin prep, and cover with dry dressing, every day shift, for DTI on the resident's coccyx (a small, triangular bone at the base of the spinal column) for 30 days. 3. Cleanse with NS, pat dry, apply skin prep, and cover with dry dressing, every day shift, for the resident's left first metatarsal (the long bones in the foot), (wound description not indicated) for 30 days. 4. Cleanse with NS, pat dry, apply [MEDICATION NAME], and cover with dry dressing every day shift, for the resident's Stage II pressure ulcer on the left medial ankle for 30 days. 5. Cleanse with NS, pat dry, apply [MEDICATION NAME], and cover with dry dressing every day shift, for the resident's Stage II pressure ulcer on the left medial foot for 30 days. 6. Cleanse with NS, pat dry, apply skin prep, and cover with dry dressing, every day shift, for the resident's DTI on the right fifth metatarsal for 30 days. 7. Cleanse with NS, pat dry, apply [MEDICATION NAME], and cover with dry dressing every day shift, for the resident's Stage II pressure ulcer on the right lateral foot for 30 days. 8. Apply Santyl Ointment (a product used to help the healing [MEDICAL CONDITION] skin ulcers by helping to break up and remove dead skin and tissue), 250 units per gm, to the resident's Stage III pressure ulcer on the left knuckle for 30 days. 9. Apply Santyl Ointment, 250 units per gm, to the resident's Stage IV pressure ulcer on the left lower forearm wrist for 30 days. 10. Apply Santyl Ointment, 250 units per gm, to the resident's Stage III pressure ulcer on the left palm of the hand to the wrist for 30 days. 11. Apply Santyl Ointment, 250 units per gm, to the resident's Stage IV pressure ulcer on the left shoulder for 30 days. 12. Apply Santyl Ointment, 250 units per gm, to the resident's Stage IV pressure ulcer on the left trochanter (site one) for 30 days. 13. Apply Santyl Ointment, 250 units per gm, to the resident's Stage III pressure ulcer on the left trochanter (site two) for 30 days. 14. Apply Santyl Ointment, 250 units per gm, to the resident's Stage IV pressure ulcer on the right trochanter for 30 days. 15. Cleanse with NS, pat dry, apply Collagen Matrix (medication used for tissue repair and regeneration), cover with dry dressing every day shift, for the resident's Stage IV pressure ulcer on the left clavicle for 30 days. A record review of the facility's Job Description titled, Treatment Nurse (TN), dated 8/2011, indicated duties and responsibilities which included completing weekly skin assessment of resident and recording results with assessment; providing treatment and therapeutic services per physician's orders [REDACTED]. On 4/11/18 at 8:25 a.m., during an interview, the Physician Assistant (PA), stated prior to admission to the GACH, Resident 1 had seven to eight wounds. The PA stated that the most concerning wound was Resident 1's Stage IV pressure ulcer to the right trochanter. The PA stated Resident 1 has contractures, and required repositioning and offloading pressure. The PA stated the resident presently had 15 pressure ulcers. On 4/11/18 at 9:03 a.m., during an observation and interview, Resident 1's low air loss mattress, was set at pressure number four, for a weight of 175 pounds. TN 1 stated the pressure firmness of the mattress is usually adjusted based on the resident's comfort. TN 1 stated that since Resident 1 was unable to verbalize comfort, the setting of the mattress was based according to the resident's weight. On 5/25/18 at 9:20 a.m., during a telephone interview and record review, the Director of Nurses (DON) stated she could not find Resident 1's Wound Weekly Monitoring/Assessment, documented by the Licensed Nurse, for the week of 12/26/17, 1/2/18, 1/9/18, and 1/16/18. The DON stated Resident 1 had Surgical Consult notes dated 1/10/18, 1/17/18, and that the measurements indicated were the same as the nurse's assessment. The DON stated the TN initially conducts independent assessment of the resident's skin, and the physician and TN assesses the resident's wound together on a weekly basis. The DON stated the TN is responsible for assessing the resident's skin condition daily during treatment through observation. The DON stated the progression of a resident's wound has the potential to change daily. 2. A review of Resident 2's Admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 2 had [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (partial or complete paralysis of the lower half of the body with involvement of both legs). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was not able to report the correct year, month, and day of the week. According to the MDS, Resident 2 was totally dependent on two or more persons for physical assistance with bed mobility, transferring between surfaces, and toilet use. The MDS indicated Resident 2 required extensive assistance from one person for eating. The MDS indicated Resident 2 was always incontinent of bowel and bladder, and had impairment to both sides of the upper and lower extremities. The MDS indicated Resident 2 did not have pressure ulcers, but was at risk for developing pressure ulcers. A review of Resident 2's Care Plan titled, Higher Risk/Potential for Pressure Ulcer Injury, Related to Decreased Mobility, Incontinent of Bowel and Bladder and Disease Process, date initiated 3/31/16, indicated interventions for staff to check the resident every two hours for soiling or wetness, and to encourage hydration and nutrition. The Care Plan indicated interventions for staff to turn and reposition the resident at least every two hours, or more often as needed. A review of Resident 2's Braden Scale, dated 1/38/18 at 10:33 a.m., indicated the resident was at high risk for developing a pressure ulcer. A review of Resident 2's Weekly Skin Check, dated 1/17/18 at 10:40 p.m., 1/24/18 at 10:22 p.m., and 1/31/18 at 2:13 p.m., indicated the resident had a reopened scab now wound to the right upper buttock. A review of Resident 2's Wound Weekly Monitoring/Assessment, dated 1/25/18 at 11:31 a.m., indicated the resident had a Stage III pressure ulcer, measured as 6.5 cm in length, 2 cm in width, and 0.2 cm in depth. A review of Resident 2's Weekly Skin Check, dated 1/31/18 at 10:01 p.m., indicated the resident had a Stage III pressure ulcer to the right upper buttock. The document did not indicate the description of the wound. A review of Resident 2's Weekly Skin Check, dated 2/7/18 at 11:03 p.m., indicated the resident had a Stage III pressure ulcer to the right trochanter. The document did not indicate the description of the wound. A review of Resident 2's Wound Weekly Monitoring/Assessment, dated 3/10/18 at 1:51 p.m., indicated the resident had a Stage II pressure ulcer in the left trochanter, measured as 1 cm in length, 1 cm in width, and 0.1 cm in depth. A review of Resident 2's Weekly Skin Check, dated 3/14/18 at 9:48 p.m., indicated the resident had a Stage III pressure ulcer to the right trochanter, and a Stage II pressure ulcer to the left hip. The document did not indicate the description of the wounds. A review of Resident 2's Treatment Administration Record (TAR), indicated an order to apply heel float boots (a boot that completely offloads the heel) at all times every shift, dated 3/26/17, and was not documented as applied on the following dates and times: 1. 12/5/17, day shift; 12/6/17, night shift; 12/23/17, day and night shift. 2. 1/4/18, day shift; 1/10/18, night shift; 1/12/18, day shift; 1/17/18, evening shift. 3. 2/8/18, day shift; 2/9/18, day shift; 2/27/18, night shift. 4. 3/14/18, day shift. A review of Resident 2's TAR, indicated an order dated 12/15/17, to cleanse the reopened scab on the resident's right upper buttock with NS, pat dry, apply triple antibiotic ointment, and cover with dry dressing daily for 21 days, every day shift, and the completion of treatment provided was not documented on the following dates: 1. 12/23/17 2. 1/4/18 3. 1/12/18 A review of Resident 2's TAR, for (MONTH) (YEAR), indicated an order dated 2/8/18, to cleanse the resident's right trochanter pressure ulcer with NS, pat dry, apply triple antibiotic ointment, and cover with dry dressing daily for 30 days, and was not documented as completed on 2/9/18 and 2/10/18. A review of Resident 2's TAR, for (MONTH) (YEAR), indicated an order dated 3/8/18, to apply [MEDICATION NAME] Ointment (an antibiotic used to treat skin infections) two (2) percent (%), to the resident's right trochanter Stage III pressure ulcer, topically for one week, every day shift, and was not documented as completed on 3/14/18. According to the TAR, an order dated 3/11/18, indicated to cleanse the resident's left hip Stage II pressure ulcer, with NS, apply [MEDICATION NAME], and dry dressing every day shift, until further orders, and was not documented as completed on 3/14/18. A review of the TAR indicated orders dated 2/22/18, to cleanse with NS, pat dry, and apply Santyl Ointment, 250 units per gm, and Collagen Matrix to Resident 2's Stage III pressure ulcer to the right trochanter, topically, every day shift for 30 days. The TAR indicated the completion of treatment provided was not documented on 3/2/18. A review of Resident 2's Care Plan titled, Skin Compromise to the Left Hip, date initiated 3/10/18, indicated an intervention for the resident to refrain from the use of incontinent pads and briefs while in bed. A review of Resident 2's Lab Results Report, dated 2/22/18 at 7:52 a.m., indicated the resident had [MEDICAL CONDITION], with a level of 152 meq/L, and [MEDICATION NAME], with a level of 3.0 gm/dL. A review of Resident 2's Documentation Survey Report, for (MONTH) (YEAR), indicated to reposition the resident at least every two hours, while in bed or on a wheelchair. The report indicated on 3/25/18 and 3/27/18, there was no documentation Resident 2 was repositioned from 8 a.m. to 2 p.m. A review of Resident 2's Interdisciplinary Progress Notes (IDT, a group of health care professionals who work toward a common goal for the patient), dated 4/16/18 at 12:01 p.m., indicated the resident's family was concerned and questioning the reason for Resident 2's skin breakdown. The note indicated the facility informed the resident's family that the resident was repositioned every two hours, or more frequently as needed, and was provided with incontinent care. A review of the facility's Policy and Procedure titled, Pressure Ulcer Risk Assessment, revision dated 11/2012, indicated that pressure ulcers are often made worse by continual pressure, heat, moisture, and irritating substances on the resident's skin (perspiration, feces, and urine). The policy and procedure indicated for nurses to conduct skin assessments at least weekly to identify changes, and for staff to maintain a Stop and Watch while performing routine skin inspections daily or every other day as needed. The Policy and Procedure indicated that at-risk residents need to be identified and have interventions implemented promptly, to attempt to prevent pressure ulcers. On 2/16/18 at 9:30 a.m., during an observation, Resident 2 was observed cachexic, lying in bed, and had a strong smell of urine. On 2/16/18 at 10 a.m., during an observation and interview, the TN 1, stated Resident 2's adult brief was wet. On 2/16/18 at 10:05 a.m., during an observation and interview, the Certified Nursing Assistant (CNA 1), stated, I saw him (Resident 2) and he was soaking wet and; it smells the room like urine. CNA 1 stated she had to clean Resident 2's mattress because the mattress was wet and smelled like urine. CNA 1 stated she checked the resident's adult brief and was soaked with urine at the beginning of her shift (at approximately 6:30 a.m.). On 4/11/18 at 8:45 a.m., during an observation and interview, CNA 2 stated Resident 2 was wearing an adult brief that was unfastened on the left side. CNA 2 stated, He (Resident 2) has to be repositioned every two hours and sometimes I'll notice that the previous shift does not change him or reposition him. Some just don't care. CNA 2 stated she has found Resident 2 soiled at the beginning of her shift, and should have been changed prior to the end of the staff's shift. On 4/17/18 at 1:05 p.m., during a telephone interview, CNA 4 stated that she reported to the Registered Nurses (RN) and LVNs that Resident 2 was soaking wet on the infected side for months and months by the night shift. On 5/23/18 at 3 p.m., during a telephone interview, the DON, stated if the resident was readmitted back to the facility on the same day the resident was transferred to the GACH; documentation on the readmission assessment is not required or applicable. The DON stated a progress note of Resident 1's readmission on 1/22/18 was documented, and should have the licensed nurse's assessment of the resident.

Based on observation, interview, and record review, the facility failed to ensure that two of two sampled residents (Resident 1 and 2), who had multiple pressure ulcers, received daily caloric intakes as ordered, and maintained the resident's nutritional status, by failing to: 1. Ensure one on one staff assistance was provided for Resident 2 during mealtimes. 2. Ensure Resident 2's meal percentage intake was monitored per Registered Dietician (RD) recommendations, plan of care, and facility's Policy and Procedure. 3. Ensure Resident 1 received enteral feedings as prescribed, to meet the recommended daily nutritional intake. 4. Assess, monitor, and record Resident 1's weekly weight for four weeks upon readmission to the facility from a General Acute Care Hospital (GACH). These deficient practices resulted in Resident 2's unplanned severe weight loss of nine (9) pounds in one month, a 5.76 percent (%) weight loss, from 3/6/18 to 4/4/18, and seven (7) pound weight loss in one week, from 4/4/18 to 4/11/18. These deficient practices placed the residents at risk for delay in pressure ulcer healing, and had the potential for Resident 1 to be at risk for unplanned weight loss, which could lead to other health complications. Findings: 1. A review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 1 had [DIAGNOSES REDACTED]. (an inherited condition in which nerve cells in the brain break down over time), Stage IV pressure ulcer,[MEDICAL CONDITIONS] (paralysis in all four limbs), contracture (a muscle or tendon that is shortened or tightened to the point it could not stretch normally), cachexia (marked weight loss and muscle loss), and protein-calorie malnutrition. A review of Resident 1's History and Physical (H & P), dated 3/18/18, indicated the resident did not have the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 2/9/18, indicated Resident 1 was not able to report the correct year, month, and day of the week, and rarely had the ability to understand others and make self-understood. According to the MDS, Resident 1 was totally dependent on one person for physical assistance with eating, toilet use, and personal hygiene, and was totally dependent on two or more persons for bed mobility. The MDS indicated Resident 1 was always incontinent (the inability to control urination or defecation) of bowel and bladder, and had impairment to both sides of the upper and lower extremities. The MDS indicated Resident 1 had three unhealed Stage III pressure ulcers, and two unhealed Stage II pressure ulcers present upon admission or reentry to the facility. The MDS indicated Resident 1's largest pressure ulcer was measured at 2.5 centimeters (cm) in length, 2.5 cm in width, and 0.2 cm in depth, and had slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps) present. The MDS indicated treatments included a pressure-reducing device for Resident 1's bed, a turning and repositioning program, and nutrition and hydration intervention to manage the resident's skin problems. A review of Resident 1's Nutritional Assessment (Admission), dated 12/28/17 at 2:30 p.m., indicated interventions to provide [DEVICE] ((gastrostomy tube), is a tube inserted through the abdomen that delivers nutrition directly to the stomach) feedings to the resident as ordered and continue to monitor weights (frequency not indicated). A review of Resident 1's Emergency Department (ED) notes, from the GACH, dated 2/22/18 at 8:40 p.m., indicated the resident presented as emaciated (excessively thin and wasted) and contracted. Resident 1's tongue is protuberant (bulging) and appears dry. The notes indicated the resident had multiple small open wounds A review of Resident 1's GACH record, dated 2/23/18, indicated the resident had [MEDICAL CONDITION] (an elevated sodium level due to dehydration or loss of body fluids), with a level of 150 milli equivalent (meq) per liter (L) (NRR is 136 to 146 meq/L). The GACH record also indicated Resident 1 had [MEDICATION NAME] (a low serum [MEDICATION NAME] level, due to the body's inability to properly absorb and digest protein, suggesting malnutrition) of 1.90 (gm) per deciliter (dL) (NRR is 3.40 to 5.00 gm/dL). A review of Resident 1's Order Summary Report, for (MONTH) (YEAR), indicated enteral feeding (the delivery of a nutritionally complete feed, directly into the stomach and intestine) orders on 3/28/18, to administer [MEDICATION NAME] (fortified therapeutic nutrition that provides complete, balanced nutrition for enteral feeding) 1.5, at 60 milliliters (ml) per hour for 20 hours, to provide 1200 ml per 1800 calories (Kcal). The order indicated to turn on the infusion at 1 p.m., and to turn off infusion at 9 a.m., or until the dosage was met. On 4/11/18 at 9:03 a.m., during an observation and interview, Resident 1's low air loss mattress, was set at pressure number four, for a weight of 175 pounds. The Treatment Nurse (TN 1) stated the pressure firmness of the mattress is usually adjusted based on the resident's comfort. TN 1 stated that since Resident 1 was unable to verbalize comfort, the setting of the mattress is based according to the resident's weight. On 4/11/18 at 2:40 p.m., during an interview, the Registered Dietician (RD) stated Resident 1 received enteral nutrition since 2/2017. The RD stated [DEVICE] patients always get weekly weights, to assess the need for changes with the resident's nutrition. On 4/11/18 at 3:55 p.m., during an observation and interview, the Certified Nursing Assistant (CNA 5) stated Resident 1's enteral feeding was turned off. On 4/11/18 at 4:40 p.m., during an observation, interview, and record review, the Licensed Vocational Nurse (LVN 2) stated Resident 1's enteral feeding is turned off from 9 a.m. to 1 p.m. LVN 2 stated per physician's orders [REDACTED]. LVN 2 stated, I'm not sure if someone turned it off to reposition him (Resident 1) or not. A review of Resident 1's Weights and Vitals Summary, indicated Resident 1 weighed 122 pounds on 12/26/17 at 9:31 p.m., 1/5/18 at 10:37 a.m., and 2/4/18 at 10:52 p.m. The summary indicated Resident 1 weighed 121 pounds on 2/21/18 at 4:04 p.m., and 113 pounds on 4/4/18 at 2:22 p.m. The Summary indicated Resident 1 was not weighed for four consecutive weeks upon admission, per facility's Policy and Procedure. 2. A review of Resident 2's Admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 2 had [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (partial or complete paralysis of the lower half of the body with involvement of both legs). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was not able to report the correct year, month, and day of the week. According to the MDS, Resident 2 was totally dependent on two or more persons for physical assistance with bed mobility, transferring between surfaces, and toilet use. The MDS indicated Resident 2 required extensive assistance from one person for eating. The MDS indicated Resident 2 was always incontinent of bowel and bladder, and had impairment to both sides of the upper and lower extremities. The MDS indicated Resident 2 did not have pressure ulcers, but was at risk for developing pressure ulcers. A review of Resident 2's Care Plan titled, Higher Risk/Potential for Pressure Ulcer Injury, Related to Decreased Mobility, Incontinent of Bowel and Bladder and Disease Process, date initiated 3/31/16, indicated interventions for staff to monitor the resident's nutritional status, serve the diet as ordered, and monitor the resident's intake and output. A review of Resident 2's Documentation Survey Report, for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), indicated the resident's amount eaten was not recorded on the following dates: 1. 3/25/18 and 3/27/18 at 9 a.m. and 1 p.m. 2. 2/6/18 and 2/10/18 at 9 a.m., 1 p.m., and 2/16/18 at 1 p.m. 3. 1/14/18, 1/20/18, and 1/23/18 at 9 a.m. and 1 p.m. 4. 12/18/17, 12/20/17, 12/25/17, 12/31/17 at 9 a.m. and 1 p.m., and 12/24/17 at 1 p.m. A review of Resident 2's Care Plan titled, Unplanned/Unexpected Weight Loss Related to Variable Food Intake, date initiated 3/10/18, indicated staff interventions to monitor and record food intake at each meal, and monitor and evaluate any weight loss. A review of Resident 2's Lab Results Report, dated 2/22/18 at 7:52 a.m., indicated the resident had [MEDICAL CONDITION], with a level of 152 meq/L, and [MEDICATION NAME], with a level of 3.0 gm/dL. A review of Resident 2's Weights and Vitals Summary, indicated the resident weighed 156 pounds on 3/6/18, 147 pounds on 4/4/18 (nine pound weight loss in one month), and 140 pounds on 4/11/18, (seven pound weight loss in one week). A review of Resident 2's Mini Nutritional Assessment, dated 3/28/18 at 1:09 p.m., indicated the resident was malnourished. A review of Resident 2's Nutritional Assessment, dated 3/28/18 at 1:11 p.m., indicated the resident's usual weight of 152 to 164 pounds. The assessment indicated the resident had a Stage III pressure ulcer to the right trochanter, measured at 6.4 cm in length, 5.4 cm in width, and 0.1 cm in depth. A review of the facility's Policy and Procedure titled, Weight Management System, revision dated 11/2012, indicated residents with poor intake of food and or fluids would have intake and output monitoring until deemed stable. The Policy indicated that food or enteral intake would be documented after each meal. The Policy indicated that Residents with poor intake, significant weight loss, cognitive or functional limitations that impair one's ability to feed self, dehydration, or other risk factors placing the resident at risk, would have appropriate measure implemented in their plan of care to promote weight gain and increase food and fluid consumption. A review of the facility's policy and procedure titled, Pressure Ulcer Risk Assessment, revision dated 11/2012, indicated that pressure ulcers are often made worse by a decline in hydration and nutrition status. On 2/16/18 at 9:30 a.m., during an observation, Resident 2 was observed cachexic, lying in bed, and had a strong smell of urine. On 4/11/18 at 3 p.m., during an interview, the RD stated Resident 2's intake fluctuates, depending on the resident's behavior. The RD stated, Most of the time, he (Resident 2) just needs supervision. On 4/17/18 at 8:20 a.m., during an observation and interview, CNA 3 stated Resident 2 requires assistance feeding, and could not feed himself. CNA 3 stated, He (Resident 2) needs total help. On 4/17/18 at 9:05 a.m., during an observation and interview, the Restorative Nursing Assistant (RNA 1) and RNA 2 weighed Resident 2, using a Hoyer lift (mechanical device used to allow a person to be lifted and transferred with a minimum of physical effort). Resident 2 was observed weighing 142.6 pounds. RNA 1 stated the sling and incontinence pad weighed approximately two pounds, and is subtracted from the resident's weight (actual weight is 140.6 pounds). On 4/17/18 at 1:05 p.m., during a telephone interview, CNA 4 stated when the facility is short staffed, sometimes she (CNA 4) does not have time to feed the residents.

Based on interview and record review, the facility failed to follow its policy and a residents plan of care to ensure one of two sampled residents (Resident 1) received the necessary care and services to prevent medical complications [REDACTED].>1. Resident 1, who had a recent history of receiving [MEDICATION NAME] (used to treat and prevent blood from clotting), with a high risk of bleeding, had several episodes of vomiting coffee ground (reddish-brown) emesis (action of vomiting) that was not adequately assessed or addressed. (Cross referenced F 757) 2. Resident 1, who was at risk for constipation due to receiving medications that caused constipation, had poor intake of food and fluids and was not being adequately assessed for constipation as per the plan of care. These deficient practices resulted Resident 1 being transferred to the general acute care hospital (GACH), being diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Record facesheet indicated the resident was originally admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 1 had [DIAGNOSES REDACTED]. to think, feel, and behave clearly), and [MEDICAL CONDITION] reflux disease ((GERD) - a condition in which stomach acid from the stomach travels back up into the esophagus). A review of Resident 1's History and Physical (H/P), dated 1/15/18, indicated the resident did not have the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 1/16/18, indicated Resident 1 was able to report the correct year, month, and day of the week, and sometimes had the ability to understand others and make self-understood. According to the MDS, Resident 1 exhibited physical and verbal behavioral symptoms directed toward others. The MDS indicated Resident 1 required extensive physical assistance from two or more persons for bed mobility, transfers between surfaces, toilet use and personal hygiene. The MDS indicated Resident 1 was always incontinent (the inability to control urination or defecation) of bowel and bladder and required a one-person physical assist to eat. A review of Resident 1's Order Summary Report, for the month of 1/2018, indicated a physician order [REDACTED]. A review of the Report indicated there was no stool softener medications ordered routinely for the resident. A review of an online drug reference from Lexi Comp titled, [MEDICATION NAME], dated 5/2/18, indicated the adverse side effects, such as constipation. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7632 A review of Resident 1's physician order, dated 1/12/18, and timed at 7:32 p.m., indicated to administer [MEDICATION NAME] Solution 30 milligrams (mg), and inject subcutaneously (under the skin), once a day for [MEDICAL CONDITIONS] - a blood clot in a deep vein) [MEDICATION NAME] (prevention). A review of Resident 1's Medication Administration Record [REDACTED]. A review of an online drug reference Lexi Comp, titled [MEDICATION NAME], dated 4/23/18, indicated medical residents with severely restricted mobility during acute illness would continue treatment until the risk of [MEDICAL CONDITION] has diminished (usually six to 11 days). The drug reference indicated possible adverse effects of [MEDICATION NAME] included bleeding, and to monitor the resident closely for signs and symptoms of bleeding. The drug reference indicated to use with caution in the elderly because delayed elimination might occur. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/6820 A review of Resident 1's Nutritional Assessment, dated 1/15/18, and timed at 1:43 p.m., indicated the Registered Dietitian's ((RD) a trained nutrition expert) nutritional interventions included to continue to monitor the resident's food intake, laboratory test results, and skin integrity. A review of Resident 1's Nurses' Weekly Look Back Summary, dated 1/17/18, and timed at 3:20 p.m., indicated Licensed Vocational Nurse 1 (LVN 1), did not record the resident's bowel sounds and patterns. A review of Resident 1's record of Amount Eaten, indicated the resident's food intake was not documented on the following dates and time: 1. 11/5/17, 11/6/17, and 11/23/17, at 9 a.m. and 1 p.m. 2. 11/7/17, 11/11/17, and 11/19/17, at 6 p.m. 3. 12/2/17, 12/6/17, and 12/15/17, at 6 p.m. 4. 1/20/18 and 1/28/18, at 9 a.m. and 1 p.m. A review of Resident 1's Fluid Intake record for the month of 1/2018, indicated the resident's fluid intake was not documented on 1/20/18 and 1/28/18, at 8 a.m. and 1 p.m. A review of Resident 1's Nurse Progress Notes, dated 1/30/18, and timed at 6 a.m., indicated the resident regurgitated (to bring already swallowed food, back up through the throat and out of the mouth). A review of Resident 1's Nurse Progress Notes, dated 1/30/18, and timed at 6:28 a.m., indicated the resident was observed in bed vomiting reddish brown thin liquid with white particles. The nurse Progress Note indicated Resident 1's physician was paged at 6:19 a.m. on 1/20/18. According to the nurse's Progress Note, Resident 1 was observed vomiting emesis at 6:44 a.m. and 7:07 a.m., for a total of three vomiting episodes. The Progress Note indicated the LVN was waiting for a return call from the physician. A review of the facility's Policy and Procedure titled, Change of Condition, Resident, revision dated 11/2012, indicated for the facility to identify, inform the physician, and resident (or designated agent), and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. The Policy and Procedure indicated if the resident's primary physician is not available in a timely manner to meet the resident's needs, to contact the on-call physician, and notify the Director of Nursing (DON) and or the Medical Director if unable to contact the on-call physician timely. The Policy and Procedure indicated in the event of a life-threatening situation, when a physician could not be contacted immediately, the charge nurse might elect to contact emergency personnel services to assist with care and possible transport to the GACH. The Policy and Procedure indicated to document all assessments and interventions on the resident's clinical record. A review of Resident 1's Nurses Progress Notes, dated 1/30/18, and timed at 9:05 a.m., three hours after the first vomiting episode, indicated Registered Nurse 1 (RN 1) paged the resident's physician again and was waiting for the physician to call back. A review of Resident 1's Nurses Progress Notes, dated 1/30/18, and timed at 10:28 a.m., over four hours after the vomiting episode, indicated RN 1 received a call back from the resident's physician, with orders to transfer the resident to the GACH. A review of Resident 1's Nurses Progress Notes, dated 1/30/18, and timed at 10:48 a.m., indicated the ambulance would arrive at the facility after one (1) hour. A review of Resident 1's Nurses Progress Notes, dated 1/30/18, and timed at 3:27 p.m., indicated Resident 1 was picked up from the facility and transferred to the GACH at 12:30 p.m. (six and one half hours after the first episode of bloody emesis). The Progress Note indicated that while moving the resident onto the gurney, the resident vomited bloody emesis again. A review of a SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique used to facilitate prompt and appropriate communication) Communication Form, dated 1/30/18, indicated Resident 1 had a change in condition of nausea and vomiting. The SBAR indicated No changes observed, was recorded on the SBAR under Abdominal and Gastrointestinal ((GI) - stomach and intestine) evaluation (sic). An online article titled, Coffee Ground Vomitus, dated 6/28/16, indicated coffee ground vomitus is vomit that looks like coffee grounds. The color of the vomited blood varies depending on how long the blood was in the gastrointestinal (GI) system and is indicative of GI bleeding. The article indicated this was a serious condition, and requires immediate medical attention. www.healthline.com/health/coffee-ground-vomitus A review of Resident 1's care plan titled, Potential for Constipation Related to Decreased Mobility, and Medication's Side Effects, date initiated 1/30/18, indicated staff's interventions included to give stool softener as per physician's orders [REDACTED]. A review of an Emergency Department (ED) Note, from the GACH, dated 1/30/18, and timed at 1:04 p.m., indicated Resident 1 was admitted to the ED via ambulance, and had coffee ground emesis since 4 a.m. A review of Resident 1's Abdominal X-Ray report from the GACH, dated 1/31/18, indicated the resident had moderate to severe fecal dilatation (the process of enlargement or expansion) of the recto-sigmoid junction (the area in the large intestine between the sigmoid colon and rectum) reflecting impaction. A review of a [MEDICATION NAME] (the branch of medicine focused on the digestive system and its disorders) Follow-up Note, from the GACH, dated 2/1/18, indicated recto-sigmoid fecal impaction and retention. On 4/11/18 at 1:47 p.m., during an interview and concurrent record review, LVN 1 stated the night shift nurse endorsed to her that Resident 1 vomited during the night shift. LVN 1 stated Resident 1 vomited one time during her shift prior to transferring to the GACH. LVN 1 stated for a resident with a change of condition, the physician should be contacted every 15 minutes and after three attempts, if the physician could not be contacted and the resident was unstable, the nurse needs to call 911 (emergency services). On 5/2/18 at 2:30 p.m., during a telephone interview and concurrent record review, the DON stated Resident 1's care plan titled, Potential for Constipation Related to Decreased Mobility, and Medication's Side Effects, was created by the staff on 1/30/18 (the day the resident was transferred to the GACH). The DON stated the goal date in the Care Plan was entered incorrect because the date should not be recorded prior to the date the care plan was created. On 5/2/18 at 4 p.m., during a telephone interview, Certified Nursing Assistant (CNA 1) stated when Resident 1 would be changed and repositioned to her side in bed, the resident would push out her poop. CNA 1 stated when the resident was laying down sometimes her stool would not come out. CNA 1 stated Resident 1 required total care from staff for all ADL's (activities of daily living) while in bed. CNA 1 stated Resident 1 sometimes ate 50 percent (%) of her meals, if she was hungry. CNA 1 stated the CNAs should record the resident's intake of meals and fluids per shift. On 5/3/18 at 10:20 a.m., during a telephone interview, the Registered Dietician (RD) stated if the resident has poor nutritional intake, and was at risk for constipation, the resident's meal and fluid intake should be monitored. The RD stated the overall recommended fluid intake for Resident 1 should be 1,000 milliters (ml) per day. On 5/3/18 at 1:51 p.m., during a telephone interview, RN 2 stated the CNAs are responsible to check and record if the resident has had a BM. RN 2 stated if the resident had no BM for three days, the LVN was responsible to assess the resident. RN 2 stated that as part of the Nurses' Weekly Look Back Summary, the LVNs were responsible to listen to the resident's bowel sounds and palpate the resident's abdomen for hardness or distention. RN 2 stated Resident 1's appetite varied, was a high risk for constipation, due to her poor nutritional intake. The RD stated, If you really want her (Resident 1) to eat, you need to feed her.

Based on interview and record review, the failed to follow its policy and procedure to ensure a resident assessed at a high risk for developing pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction), received appropriate interventions and accurate skin assessments, to prevent the development of pressure ulcers for one of two sampled residents (Resident 1), by failing to: 1. Perform a weekly skin check for Resident 1 per the facility's policy and procedure. 2. Follow Resident 1's plan of care to reposition the resident every two hours, and provide a pressure-reducing device for the resident's bed. 3. To revise Resident 1's plan of care specific to the needs of the resident. 4. Monitor Resident 1's meal and fluid intake per the Registered Dietitian ((RD) food and nutrition experts) recommendations. Resident 1, who was readmitted to the facility on [DATE] with intact skin, developed a sacrocoxxyx (a large triangular bone at the base of the spine down to the tailbone), Stage IV pressure ulcer (skin break with deep tissue involvement) with necrotic (death of cells through injury or disease, especially in a localized area of a tissue or organ) tissue present. These deficient practices resulted in Resident 1 developing a Stage IV pressure ulcer, which required debridement (the removal of damaged tissue from a wound) of the pressure ulcer wound at the general acute care hospital (GACH). Findings: A review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on [DATE], and was last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. artery walls). A review of Resident 1's History and Physical (H/P), dated 1/15/18, indicated the resident did not have the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 1/16/18, indicated Resident 1 was able to report the correct year, month, and day of the week, and sometimes had the ability to understand others and be understood. According to the MDS, Resident 1 exhibited physical and verbal behavioral symptoms directed toward others. The MDS indicated the resident required extensive physical assistance from two or more persons for bed mobility, transfers between surfaces, toilet use and personal hygiene. The MDS indicated Resident 1 was always incontinent (the inability to control urination or defacation) of bowel and bladder, and required extensive assistance from one person to eat. The MDS indicated Resident 1 was at risk for developing pressure ulcers, and indicated the resident had no unhealed pressure ulcers at Stage I (a reddened, painful upper layer of the skin that does not turn pale when pressed firmly) or higher. The MDS indicated Resident 1 would be provided with a pressure-reducing device for the bed. A review of Resident 1's care plan titled, At Risk for Pressure Ulcer Development or Skin Impairment, dated 10/7/17, indicated staff interventions as follows: Encourage good nutrition and hydration (fluid) in order to promote healthier skin; Identify/document potential causative factors and eliminate/resolve where possible; Reposition every two hours or as determined turning/repositioning when in bed/chair; Nutritional approaches per the RD recommendations and ordered by the physician. A review of Resident 1's care plan titled, Unplanned and Unexpected Weight Loss Related to Poor Food Intake, dated 10/17/17, indicated staff interventions to monitor and record food intake at each meal, and to alert the RD if consumption of the resident was poor for more than 48 hours. A review of Resident 1's Admit/Readmit Assessment, dated 1/12/18, and timed at 8:37 p.m., indicated the resident was readmitted to the facility with Skin clear and intact upon readmission. A review of Resident 1's Order Summary Report, dated 1/12/18, indicated to monitor the resident's skin daily for 21 days for redness, rash, and skin discoloration. The report indicated to document none (-) and presence (+), every day shift. A review of Resident 1's Nutritional Assessment, dated 1/15/18, and timed at 1:43 p.m., indicated the RD's nutritional interventions included to continue to monitor the resident's intake, laboratory test results, and skin integrity. A review of Resident 1's Weekly Skin Check, dated 1/17/18, and timed at 3:20 p.m., five days after readmission, indicated the resident did not have any identified abnormal skin condition. A review of Resident 1's record of Amount Eaten, indicated the resident's food intake was not documented on the following dates and time: 1. 11/7/17, 11/17/17, and 11/19/17, at 6 p.m. 2. 11/5/17, 11/6/17, and 11/23/17, at 9 a.m. and 1 p.m. 3. 12/2/17, 12/6/17, and 12/15/17, at 6 p.m. 4. 1/20/18 and 1/28/18, at 9 a.m. and 1 p.m. A review of Resident 1's Weights and Vitals Summary indicated the resident had a 14 pound weight loss from 12/5/17 to 1/30/18. A review of Resident 1's Fluid Intake record for the month of 1/2018, indicated the resident's fluid intake was not documented on 1/20/18 and 1/28/18, at 8 a.m. and 1 p.m. A review of Resident 1's Pressure Ulcer Risk Assessment, dated 1/26/18, and timed at 8 p.m., indicated the resident was at high risk for developing a pressure ulcer. A review of Resident 1's Treatment Administration Record (TAR), for the month of 1/2018, indicated from 1/13/18 to 1/25/18, and 1/27/18 to 1/30/18, the resident did not have any presence of redness, rash, or skin discoloration. The TAR indicated there was no documentation of Resident 1's skin monitoring on 1/26/18. A review of Resident 1's Nursing Home to Hospital Transfer Form, dated 1/30/18, and timed at 11:17 a.m., indicated the resident was transferred to the GACH with no pressure ulcers, and was documented as N/A (not applicable). A review of Resident 1's Health Status Note, dated 1/30/18, and timed at 3:27 p.m., indicated Licensed Vocational Nurse 1 (LVN 1) documented that Resident 1 did not have any wounds before transferring to the GACH. A review of the Resident 1's GACH Admission Assessment, dated 1/30/18, and timed at 1:04 p.m., indicated the resident was admitted with a decubitus pressure ulcer to the coxxyx area. A review of a Physician Consult Note, from the GACH, dated 1/31/18, and timed at 2:05 p.m., indicated Resident 1 had an unstageable (full thickness tissue loss, in which the actual depth of the ulcer was obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) dead tissue in the wound bed) sacral wound, with surrounding erthema (redness of the skin) and back [MEDICAL CONDITION] (bacterial skin infection). A review of the GACH's Critical Care Medicine Consultation Report, dated 1/31/18, indicated Resident 1 had been eating poorly, with [MEDICATION NAME] (protein) level of 1.8 (Normal Reference Range (NRR) 3.4 to 5.4). A review of a Physician Discharge Summary Note, from the GACH, dated 3/18/18, and timed at 11 a.m., indicated Resident 1 underwent an excisional debridement of the Stage IV sacral decubitus ulcer (pressure ulcer). The Summary Note indicated the pathology report of the sacral pressure ulcer showed An acute inflammation (an immune response that causes redness and swelling of an area on the body) and soft tissue necrosis. A review of the facility's policy and procedure titled, Weight Management System, with a revision date of 11/2012, indicated all returning admission residents would have intake and output monitoring if clinically indicated, and to document any fluid intake in milliliters (ml). A review of the facility's policy and procedure titled, Assessment, Body, with a revision date of 11/2012, indicated the certified nursing assistants would check the resident's skin on scheduled shower days and should report any skin integrity impairment to the Licensed Nurses for follow-up. According to the policy and procedure, the Licensed Nurse should perform weekly skin check according to the weekly summary schedule and document skin check completed and findings in the weekly summary. A review of the facility's policy and procedure titled, Pressure Ulcer Risk Assessment, with a revision date of 11/2012, indicated to implement Stop and Watch, and to review the resident's care plan to assess for any special needs of the resident. According to the policy and procedure pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (perspiration, feces, and urine). The nurses should conduct skin assessments at least weekly to identify changes and the staff to maintain a Stop and Watch while performing routine skin inspections that at-risk residents needed to be identified and have interventions implemented promptly in the attempt to prevent pressure ulcers. On 4/11/17 at 1:47 p.m., during an interview and concurrent record review, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's skin was intact upon transfer to the GACH on 1/31/18. LVN 1 stated the resident required assistance for ADL (activities of daily living) care and eating. LVN 1 stated the resident was at high risk for developing a pressure ulcer because the resident was bed bound (bedridden), the resident was bony and frail (weak, delicate), and the resident had limited independent mobility. On 5/2/18 at 9 a.m., during a telephone interview, the Director of Nursing (DON) stated the Certified Nursing Assistants (CNA) or staff completes the Stop and Watch record only if there was a change in the resident's skin or condition detected. The DON stated the CNA gives the record to the Charge Nurse to assess the resident. The DON stated the Stop and Watch record was a precursor to the SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique used to facilitate prompt and appropriate communication). The DON stated if there are no abnormalities of the resident's condition, the Stop and Watch record was not required. O 5/2/18 at 2:30 p.m. during a telephone interview and concurrent record review, the DON stated Resident 1's laboratory results, dated 12/29/17, and timed at 9:43 a.m., was the most current record, and was obtained from another GACH, previous to the resident's readmission to the facility on [DATE]. The record indicated the resident's [MEDICATION NAME] level was 1.8. The DON stated Resident 1 did not have by laboratory tests at the facility. The DON stated Resident 1 only had a Weekly Skin Check documented for the week of 1/22/18 (one week prior to transferring to the GACH). The DON stated the CNA should document repositioning the resident every two hours, located in the facility's computer system under Task. On 5/2/18 at 4 p.m., during a telephone interview, CNA 1 stated Resident 1 required total care from staff for ADLs while in bed. CNA 1 stated the resident sometimes ate 50 percent (%) of her meals, if she was hungry. CNA 1 stated the CNAs should record the resident's intake of meals and fluids per shift. CNA 1 stated the resident did not have a special air mattress or a cushion on the seat of the resident's wheelchair. CNA 1 stated she repositioned Resident 1 every two hours, but every three hours, if she was busy or did not have time. CNA 1 stated Resident 1 was very combative and aggressive. On 5/3/18 at 10:20 a.m., during a telephone interview, the RD stated Resident 1 had poor nutritional intake, the resident was at risk for pressure ulcer development, and the resident's meal and fluid intake should be monitored. The RD stated the overall recommended fluid intake of Resident 1 should be 1,000 ml per day. According to the National Pressure Ulcer Advisory Panel (NPUAP), low serum [MEDICATION NAME] and protein puts residents at a higher risk of developing pressure ulcers, because poor nutritional status was a contributing factor in pressure sore development and impaired wound healing. The NPUAP indicated encouraging individuals at risk for pressure injury to consume adequate fluids and a balanced diet, assess weight changes over time, assess the adequacy of oral, enteral and [MEDICATION NAME] intake, and provide nutritional supplements between meals and with oral medications, unless contraindicated were ways to prevent pressure ulcers. www.npuap.org

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from unnecessary medications. Resident 1 was receiving [MEDICATION NAME] (a medication used to treat and prevent blood from clotting) injections for eight days, without adequate monitoring for adverse consequences, as evidenced by: 1. No laboratory blood test to identify the resident's baseline. 2. No comprehensive plan of care created for [MEDICATION NAME] use. 3. No routine assessment and monitoring for possible adverse reactions or side effects of [MEDICATION NAME]. This deficient practice resulted in Resident 1 being transferred to the general acute care hospital (GACH) and being diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Record facesheet indicated the resident was originally admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 1 had [DIAGNOSES REDACTED]. to think, feel, and behave clearly), and [MEDICAL CONDITION] reflux disease ((GERD) - a condition in which stomach acid from the stomach travels up into the esophagus) A review of Resident 1's History and Physical (H/P), dated 1/15/18, indicated the resident did not have the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 1/16/18, indicated Resident 1 was able to report the correct year, month, and day of the week, and sometimes had the ability to understand others and be understood. According to the MDS, Resident 1 exhibited physical and verbal behavioral symptoms directed toward others. The MDS indicated Resident 1 required extensive physical assistance from two or more staff for bed mobility, transfers between surfaces, toilet use and personal hygiene. The MDS indicated Resident 1 was always incontinent (inability to control urination or defecation) of bowel and bladder, and required a one-person physical assist to eat. A review of Resident 1's physician order, dated 1/12/18, and timed at 7:32 p.m., indicated to administer [MEDICATION NAME] Solution 30 milligrams (mg), and inject subcutaneously (under the skin), once a day for [MEDICAL CONDITIONS] - a blood clot in a deep vein) [MEDICATION NAME] (prevention). A review of Resident 1's Health Status Note, dated 1/19/18, and timed at 1:40 p.m., indicated the resident's family member (FM 1) was very concerned about blood thinner, [MEDICATION NAME]. The Note indicated Registered Nurse 1 (RN 1) requested the physician to discontinue the [MEDICATION NAME] injections. A review of the physician's orders [REDACTED]. A review of Resident 1's Medication Administration Record [REDACTED]. A review of a Nurses Progress Note, dated 1/30/18, and timed at 6:28 a.m., indicated the resident was observed in bed vomiting reddish brown thin liquid with white particles. The Note indicated the physician was paged at 6:19 a.m., and Resident 1 was observed with vomiting again at 6:44 a.m. and 7:07 a.m., for a total of three vomiting episodes. The Note indicated the Licensed Vocational Nurse (LVN) was waiting for a return call from the physician. A review of the Emergency Department (ED) Note, from the GACH, dated 1/30/18, and timed at 1:04 p.m., indicated the resident was admitted via ambulance, and had coffee ground emesis since 4 a.m. An online article titled, Coffee Ground Vomitus, dated 6/28/16, indicated coffee ground vomitus is vomit that looks like coffee grounds. The color of the vomited blood varies depending on how long the blood was in the gastrointestinal (GI) system and is indicative of GI bleeding. The article indicated this was a serious condition, and requires immediate medical attention. www.healthline.com/health/coffee-ground-vomitus A review of the Physician Discharge Summary Note, from the GACH, dated 3/18/18, and timed at 3:49 p.m., indicated Resident 1 had a discharge [DIAGNOSES REDACTED]. A review of an online drug reference Lexi Comp, titled [MEDICATION NAME], dated 4/23/18, indicated medical residents with severely restricted mobility during acute illness would continue treatment until the risk of [MEDICAL CONDITION] has diminished (usually six to 11 days). The drug reference indicated possible adverse effects of [MEDICATION NAME] included bleeding, and to monitor the resident closely for signs and symptoms of bleeding. The drug reference indicated to use with caution in the elderly because delayed elimination might occur. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/6820 On 5/2/18 at 2:30 p.m., during a telephone interview and concurrent record review, the Director of Nursing (DON) stated Resident 1's Laboratory Result record, dated 12/29/17, and timed at 9:43 a.m., was the most current record, and was obtained from another GACH, previous to the resident's readmission to the facility on [DATE]. The DON concurred the record did not indicate Resident 1 had a blood test result for platelet (small blood cells that help the body form clots to stop bleeding) count. The DON stated Resident 1 did not have laboratory tests obtained after readmission to the facility on [DATE]. The DON stated Resident 1 did not have a care plan for the use of [MEDICATION NAME] and a resident receiving [MEDICATION NAME] should be monitored for the potential risk of bleeding. The DON stated Resident 1 was receiving [MEDICATION NAME] at the previous GACH and the physician continued the medication upon readmission to the facility (1/12/18) but they should have monitored it. On 5/3/18 at 1:51 p.m., during a telephone interview, RN 2 stated that possible side effects of [MEDICATION NAME] use was bleeding and bruising. RN 2 stated that sometimes the physician would order baseline labs to identify if the medication would need to be continued. RN 2 stated the physician would decide if the [MEDICATION NAME] would be continued. RN 2 stated the resident would need to be routinely monitored for side effects or complications of bleeding. RN 2 stated if a resident was receiving [MEDICATION NAME], a care plan should be created specific to caring for a resident receiving [MEDICATION NAME].

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was not verbally abused and threatened by Resident 2, who had a history of [REDACTED]. This deficient practice resulted in Resident 1 expressing fear and mental anguish and had the potential of jeopardizing the safety and well-being of Resident 1 and other residents in the facility. Findings: A review of Resident 1's Admission Record, indicated the resident was originally admitted to the facility on [DATE], and last readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 10/21/17, indicated the resident was able to understand others and be understood. The MDS indicated the resident was able to report the correct year, month, and day of the week. According to the MDS, the resident was able to recall words with no cues required. The MDS indicated Resident 1 exhibited hallucinations, delusions, and verbal behavioral symptoms directed toward others, such as threatening, screaming, and cursing at others. A review of Resident 1's Progress Note, dated 12/30/17 and timed at 3:07 p.m., indicated the resident had an altercation with another resident (Resident 2). The note indicated Resident 2 made terrorist threats toward Resident 1, and threatened his family because Resident 1 would not share his drink with Resident 2. A review of Resident 2's Admission Record, indicated the resident was initially admitted to the facility on [DATE], and last readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. or behavioral self-control), and dementia (a decline in mental ability severe enough to interfere with daily life) without behavioral disturbance. A review of Resident 2's Care Plan titled, Increased Risk for Conflict with Other Peers/Residents/Staff, date initiated on 3/20/15, indicated the staff's interventions included to identify increasing or escalating behaviors that required re-evaluation, identifying specific behaviors that placed the resident at risk, such as yelling, demanding, and aggressive behaviors, and to monitor behaviors daily and review increasing behaviors requiring re-evaluation. A review of Resident 2's MDS, dated [DATE], indicated the resident was usually able to understand others and usually be understood. The MDS indicated Resident 2 was only able to report the correct day of the week and recalled three of three words repeated to him after cueing. The MDS indicated Resident 2 exhibited hallucinations and delusions. A review of Resident 2's Progress Notes, dated 12/29/17 at 7:57 p.m., indicated that Resident 2 wanted Resident 1's drink, but Resident 1 refused. The Progress Note indicated Resident 2 told Resident 1 he would take his drink, suck his d---(a slang word for penis (male genital organ)). The Progress Note indicated Resident 2 became upset and Resident 2 threatened Resident 1. The Progress Note indicated the verbal exchange was very aggressive. A review of Resident 2's Progress Note, dated 12/29/17 and timed at 8:06 p.m., indicated Licensed Vocational Nurse (LVN 1) was notified of Resident 2's aggressive behavior and severe agitation, manifested by threatening peers. LVN 1 indicated Resident 2 would be transferred to a general acute care hospital (GACH) for behavior management. A review of Resident 2's [MEDICAL CONDITION] (a mood-altering drug that affects the mental activity, behavior, or perception) Summary Sheet, dated 11/2017, indicated the resident manifested 90 behavioral episodes of responding to internal stimuli (one's feelings from within, that elicits a behavioral response). A review of Resident 2's Medication Administration Record [REDACTED]. A review of the facility's Policy and Procedure titled, Abuse Prevention and Prohibition Program, revision dated 4/2017, indicated that each resident had the right to be free from verbal and mental abuse. The policy indicated that the supervisor should immediately intervene, correct, and report identified situations where abuse is at risk for occurring. The policy indicated if a resident was reported, discovered or suspected, where the health, welfare or safety of the residents were involved, the facility would provide a safe environment for the resident. The policy indicated if the suspected perpetrator was another resident, the facility would separate the residents immediately so they would not interact with each other until circumstances of the reported incident could be determined. On 1/3/18 at 11 a.m., during an interview, Resident 1 stated on 12/29/17, while in the facility's dining room, Resident 2 verbally threatened him. Resident 1 stated Resident 2 told him he was going to murder his family, and make the resident's family suck his d---, and was going to kick my a--. Resident 1 stated Certified Nursing Assistant (CNA 1) was begging for staff to remove Resident 2 from the dining room, but several staff members witnessed and heard Resident 2 threatening Resident 1 and did not intervene. Resident 1 stated he was upset because a CNA removed Resident 2 from the dining room after the altercation, but returned the resident back to the dining area nine minutes later, unsupervised. Resident 1 stated, They should have separated us. Resident 1 stated Resident 2 was taunting him by simulating the motion of masturbating in front of Resident 1 after the CNA brought Resident 2 back to the dining area. On 1/3/18 at 3:10 p.m., during an interview, CNA 1 stated Resident 2 wanted Resident 1's drink and attempted to approach Resident 1 three times. CNA 1 stated Resident 1 was yelling, Don't come to me. Get away! CNA 1 stated Resident 2 was cursing at Resident 1 and the residents were separated, but shortly after, CNA 2 brought Resident 2 back to the dining room to eat. CNA 1 stated, I told her not to bring him (Resident 2), I know they need to separate them (Resident 1 and Resident 2). CNA 1 stated Resident 2 had a disruptive behavior and would curse in a loud tone. On 1/3/18 at 3:29 p.m., during an interview, the Social Services Worker (SSW) stated she removed Resident 2 from the dining room and brought him to her office to calm down, after hearing a commotion. The SSW stated that afterwards, a nurse brought Resident 2 back to the dining room to eat his dinner. The SSW stated Resident 2 had behaviors of being loud, yelling, and would ask for money from other people. On 1/3/18 at 3:52 p.m., during an interview, the Social Services Director (SSD) stated Resident 1 appeared upset when the resident informed the SSD that Resident 2 cursed at him and told him to suck his d---. The SSD stated Resident 2 should have stayed inside the SSW's office after the altercation, and both residents (Resident 1 and Resident 2) should have remained separated to avoid another altercation. The SSD stated, No one should be talked to like that. On 1/3/18 at 4:40 p.m., during an interview, the Director of Nursing (DON) stated she was unaware of Resident 2's verbal altercation with Resident 1. The DON stated Resident 2 was sent to the GACH because he exhibited behavioral issues, but did not investigate the cause of Resident 2's transfer to the GACH. The DON stated that staff should follow the facility's Abuse Policy and Procedure. The DON stated the exchange of curse words between residents happens all the time, and stated, They are psych ((psychiatric) refers to mental disorders) residents.

Based on observation, interview, and record review, the facility failed to follow a plan of care and the Interdisciplinary Team's ((IDT) professional staff who makes decisions about a resident's care) recommendations to ensure one of two sampled residents (Resident 1) was provided with proper and safe technique in using assistive devices, as per the facility's policy and the manufactures guidelines. The facility's staff was observed improperly transferring Resident 1 from the bed to the wheelchair using a Hoyer Lift (an assistive medical device used to transfer from a bed to a wheelchair, toilet, or chair), in which the lift almost fell on the resident. This deficient practice resulted in Resident 1 sustaining multiple bruises and skin tears, which had the potential for the resident to bleed and wounds to become infected and had an episode of falling out of the Hoyer lift. The ongoing unsafe technique use of the assisted devices had the potential for the resident to sustain more serious injuries, such as fractures. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. left dominant side. A review of Resident 1's Minimum Data Set ((MDS), a resident assessment and care-screening tool), dated 7/21/17, indicated Resident 1 was able to report the correct year, month and day of the week. The MDS indicated the resident's memory was intact and had the ability to express ideas, wants and had the ability to understand other's verbal content. The MDS indicated Resident 1 was totally dependent (full staff performance) on two or more staff for physical assistance with transferring (moving between surfaces). The MDS indicated the resident required the extensive assistance (resident involved in activity, with staff providing weight-bearing support) on two or more staff with physical assistance for bed mobility and toilet use. The MDS indicated Resident 1 had impairment to one side of the upper extremity and on both sides of the lower extremity, and used a wheelchair for mobility. A review of Resident 1's Care Plan titled, At Moderate Risk for Falls, dated 10/13/16, indicated the staff's interventions included to provide and maintain a safe and hazard free environment. A review of Resident 1's Care Plan titled, At Risk for Pressure Ulcer, dated 11/7/16, indicated interventions for the resident to be provided with an extensive two-person assistance with bed mobility. The Care Plan indicated to handle the resident gently during nursing care, and to observe for redness, discoloration, and open sites during provision of care. A review of Resident 1's Change of Condition (C(NAME)) Evaluation Record, dated 6/15/17, timed at 11:24 a.m., indicated the resident had a skin tear to the left forearm, measuring 2.3 centimeters (cm) in length, and 0.3 cm in width, with no bleeding noted. The record indicated an antibiotic (used to treat many common infection) ointment was provided as a treatment. A review of Resident 1's Change of Condition (C(NAME)) Evaluation Record, dated 7/16/17, and timed at 4:10 p.m., indicated the resident had an open wound to the rear of the left lower leg, with no measurements documented. The record indicated when the resident rubs the affected area, the condition or symptoms worsen. The record indicated antibiotic ointment, covered with dry dressing was provided as treatment. A review of Resident 1's Health Status Note, dated 7/17/17, and timed at 9 p.m., indicated the resident called the Police Department and indicated that his bruises (a discoloration of the skin resulting from bleeding underneath the skin) were caused from the gurney (a wheeled stretcher used for transporting) lifts (sic). A review of Resident 1's Health Status Note, dated 7/18/17, and timed at 1:44 p.m., indicated the resident had red and brown discolored marks on his left arm, with measurements of 7 cm in length and 8 cm in width. The note indicated Resident 1 stated, Having bruises caused by the gurney lifts, and Geri-Sleeves (breathable cotton-blend that protects against skin irritation and injury) were applied on the resident. A review of Resident 1's Social Services Progress Note, dated 7/18/17, and timed at 6:33 p.m., indicated the resident was observed with a bandage on his right arm. The note indicated Resident 1 informed the social services director (SSD) that his right arm was injured while on a Hoyer Lift. The note indicated the resident stated, They were rushing. A review of Resident 1's Social Services Progress Note, dated 7/18/17 and timed at 6:48 p.m., indicated the resident had a bruise on his left arm and informed the SSD that the doors accidentally hit his arm and knee. A review of Resident 1's IDT Progress Note, dated 7/19/17, timed at 9:37 a.m., indicated on 7/17/17, staff observed a discoloration to the resident's right elbow. The note indicated Resident 1 informed staff that the bruises were caused from the gurney lifts and while Resident 1 was transferred back to bed, another staff member observed a skin tear. The skin tear measured 0.1 cm in length and 0.1 cm in width, with discoloration to the right elbow. The note indicated on 7/17/17 at 1:30 p.m., a social service assistant (SSA), observed Resident 1 on his electric wheelchair with blood on his right elbow. The note also indicated the IDT recommended for the staff to be educated on proper use of the Hoyer Lift and to apply Geri-Sleeves to Resident 1's arms to minimize potential future injuries. A review of Resident 1's Change of Condition (C(NAME)) Evaluation Record, dated 7/24/17 at 10:42 p.m., indicated the resident had open ecchymosis (bruises) on the left arm. The record indicated the wound was measured at 1.5 cm in length and 0.5 cm in width, and was discovered while the resident was being showered by an unidentified certified nursing assistant (CNA). The record indicated frequent repositioning and the use of Geri Sleeves would help improve the condition or symptom. The record indicated normal Saline (a sterile solution) with an antibiotic ointment was provided for the wound treatment. On 7/31/17 at 4:35 p.m., during an observation tour of the facility and a concurrent interview with the Assistant Director of Nursing (ADON), Resident 1 was observed lying supine (face up) in bed with his left arm elevated on top of pillows without Geri-Sleeves in place. Resident 1's arm was observed with multiple patches of uneven circular dark red discolorations to the left lower arm (approximately the diameter size of a quarter coin). Resident 1 was observed with patches of uneven, circular redness on the right elbow with a small skin tear. Resident 1 was observed unable to independently move his left arm and stated he could not feel sensation on his left upper extremity. Resident 1 stated his arm hitting the wall might have caused the bruises to his left arm. Resident 1 stated the redness and skin tear occurred while being transferred on a sling (Hoyer Lift). The ADON stated the skin tear and redness on Resident 1's right arm occurred while being transferred on the Hoyer Lift two weeks prior. On 8/14/17 at 8:40 a.m., during an observation and interview, Resident 1 stated in the past, he had fallen from the Hoyer Lift and sustained bruises (Resident 1 could not recall specific dates). On 8/14/17 at 9:30 a.m., during an observation of CNAs 1 and 2 transferring Resident 1 from the bed to the wheelchair, using a Hoyer Lift, the resident was observed positioned directly facing CNA 1 (away from the Hoyer Lift), while the machine was lifting the resident. CNA 2 positioned Resident 1's wheelchair in between the legs (base) of the Hoyer Lift, with the wheelchair facing CNA 1, and the back of Resident 1, away from the Hoyer Lift. The rear locks of the Hoyer Lift were observed unlocked while the resident was being lowered onto the wheelchair. When Resident 1 was observed sitting on the wheelchair facing CNA 1, the Hoyer lift fell back, slightly sideways, toward the resident. The Hoyer Lift was observed unbalanced, while CNA 1 was on the floor, holding the base of the Hoyer Lift, and CNA 2 was holding the top part of the lift, pushing the machine away from Resident 1 and back to an upright position to prevent the lift from falling on the resident. On 8/14/17 at 9:40 a.m., during an observation and interview, CNA 2 stated the Hoyer Lift might have fallen on Resident 1 because the resident weighs more than the Hoyer Lift's maximum weight. CNA 2 stated he thought the Hoyer Lift can hold up to 300 pounds. On 8/14/17 at 10 a.m., during an interview, CNA 1 stated the Hoyer Lift lost balance and slightly fell over sideways on Resident 1 and CNA 2. CNA 1 stated the Hoyer Lift might have fallen because the wheelchair was not inserted all the way inside between the legs of the Hoyer Lift. CNA 1 stated CNA 2 was still trying to adjust the position of the wheelchair to be centered after the resident was lowered down to the seat of the wheelchair, but the Hoyer Lift fell . CNA 1 stated the incorrect position of the wheelchair and the resident's weight contributed to the Hoyer Lift falling. A review of Resident 1's Monthly Weight Record, dated 8/3/17, indicated the resident weighed 254 pounds. On 8/14/17 at 2:47 p.m., during an interview, Restorative Nursing Assistant 1 ((RNA 1) trained to help in restoring resident's mobility), stated when using a Hoyer Lift to transfer a resident, one staff member should position the wheelchair in between the legs of the Hoyer Lift. RNA 1 stated once the wheelchair was in between the legs of the Hoyer Lift, facing the machine, the wheelchair and rear wheels of the Hoyer Lift are locked while lowering the resident. RNA 1 stated the resident should be positioned facing directly in front of the Hoyer Lift, while on the sling. RNA 1 stated the Hoyer Lift can hold up to a maximum weight of 400 pounds. On 9/19/17 at 1:55 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1), stated Resident 1 had fragile (delicate, vulnerable and easily damaged) skin and it was important that the Geri Sleeves are applied to the resident's arms, and to ensure pillows are placed below the arms for support and to prevent his left arm from hitting anything. LVN 1 stated the resident's left arm was weak, and he used his right arm to assist his left arm. LVN 1 stated she observed Resident 1's Geri Sleeves were not physically on the resident's arms. A review of the undated Instruction Guide for the Hoyer Lift, indicated before lifting the resident, ensure that the lifting accessory was correctly attached to the lift, and safely applied to the resident to prevent injuries. The guide indicated to ensure that the sling's strap loops are correctly connected to the sling bar hooks when the sling straps are stretched up before the resident is lifted from the underlying surface. The guide indicated unbalanced lifted poses a tipping risk. The guide indicated the wheels should be locked if there is a risk of the lift rolling into the resident. The guide indicated the resident should be positioned facing the lift, and that an improper lift could be uncomfortable for the user and cause damage to the lift equipment. The guide indicated the Hoyer Lift's maximum weight capacity was 440 pounds. A review of the facility's Policy and Procedure, titled, Lifting Residents by use of Mechanical Device, revision dated 12/2012 indicated the facility's staff are to follow the manufacturer's instructions for use of each specific type of lifting machine. The policy and procedure also indicated to ensure the resident was turned facing the staff and not to pull the resident backward when transferring a resident from a bed to a chair.

Based on observation, record review and interview, the facility failed to develop a written plan of care that ensure that a resident (Resident 1) received adequate supervision to meet his toileting needs and prevent falls for one of one sampled resident. As a result of this failure, Resident 1, who was assessed to be at a righ risk for falls, had a fall and sustained a right hip fracture which required surgery. Findings: On 9/29/16, at 2:35 p.m., an unannouced visit to the facility was conducted to initiate an entity reported incident by the facility. On this date and time, the site of the resident's fall was observed and noted that Resident 1 was still in the acute hospital where he had surgery of the right hip due to the fracture sustained from a fall. A review of the medical record of Resident 1 indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. His Minimum Data Set (MDS/a standardized assessment and care screening tool) dated 9/26/16, assessed the resident as being totally dependent in all areas of activities of daily living (ADL) and bowel and bladder (B and B) incontinent. The fall risk assessment for Resident 1 dated 9/25/16, indicated he was a high risks for falls related to confusion, gait/balance problem, incontinency and unawareness of safety needs. The assessment also indicated the resident was verbally and physically abusive, noisy and screams, required hands on assistance to move from place to place, and exhibits jerking or instability. Resident 1's record also indicated that on 9/25/16, the physician ordered low bed with a floor mattress related to fall risk. To prevent falls, the resident 's plan of care included hourly monitoring by staff and for the resident's bed to be in a low position at night. The Certified Nurses Assistant's (CNA 1) notes on admission indicated the resident was yelling and non-compliant. In an interview on 9/29/16 at 4:30 p.m., concurrent with record review, the Director of Nurses (DON) indicated she did not see any documentation that the CNA's notes were reviewed and that the resident's above behavior should have been care planned. The DON stated she did not see any documentation that Resident 1's bed was in a low position and that a pad (mattress) was provided per physician's orders [REDACTED]. She also stated the RN did not set up in the task portion of the CNA's charting that the resident should be monitored for fall every one hour as care planned. During a telephone interview on 10/3/16 at 2:00 p.m., LVN 1 was asked what the night licensed person reported to her. LVN 1 stated that the night shift informed her that Resident 1 was a new admit but that she was not informed that the resident was at a high risk for falls or that he was to be monitored every hour as care planned. On 10/5/16 at 10:00 a.m., during an interview, Registerd Nurse Supervisor (RNS) stated she admitted Resident 1 around midnight. She stated she completed the Admission Assessment but did not complete the Fall Risk Assessement Tool. She also stated she never saw the resident but presumed that he was at risk for fall because of the Parkinson's disease. She further stated she did a care plan for the resident which was computer generated and failed to notice that she checked the every hour monitoring and if that was the accurate or achievable intervention for the resident. In another interview on 10/5/16 at 4:38 p.m., the DON stated that the intervention or the task should be documented in the DOCUMENTATION SURVEY REPORT where the CNAs record their care. She stated the CNAs are alerted from this report of the intervention for fall management and other care throughout the task identified in the report. She also stated that the care plans are supposed to be communicated to the CNAs and other licensed staff and documented as done. If the floor pad was provided and the low bed positioned, the staff should have documented that. She further stated I don't see that these were documented and also stated the documentation was not complete. On 10/12/16 at 12:45 p.m., during an interview, Resident 1's primary caregiver, (CNA 1) stated that on 9/25/16, the resident was confused and insisted he wanted to go to the bathroom. She noticed the resident was weak, slow and unsteady, so she called someone for help. She stated she did not remember if the resident had a floor pad or bed alarm and that the resident was a new admit. She added that no one told her to monitor Resident 1 every hour or that he was a high risk for falls. On 11/1/16 at 11:00 a.m., in a telephone interview, LIcensed Vocational Nurse (LVN 2 ) stated that during the first hour after Resident 1's admission, the resident was trying to get up and go to the bathroom. She stated the resident was yelling at her, was combative and was getting frustrated because he wanted to go to the bathroom. When asked if she communicated this resident's behavior to the registered nurse (RN) to ensure a care plan was developed, she stated No and stated that the RN usually do the care plans on admission. At 11:20 a.m., on 11/1/16, during a telephone interview, the Assistant Director of Nurses (ADON) stated Resident 1's records indicated the resident was yelling and screaming but she did not see a care plan. She also stated that the RNS should have developed a care plan in order to prevent a fall and meet the resident's needs re: toileting. On 9/25/16 at 10:20 a.m., the medical records indicated Resident 1 had a fall where he sustained an acute greater trochanter avulsion fracture ( a bone of the hip that breaks and tears away from the main part of the bone) of the right hip. He was then transferred to the acute hospital where he had a surgical intervention.

Based on observation, interview, and record review, the facility failed to ensure that a certified nursing assistant (CNA 1) followed the facility ' s policy and procedure for the use of a mechanical lift/Hoyer lift (assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, using hydraulic power) and timely reporting of accidents for one of one resident (Resident 1). CNA 1 used a Hoyer lift and transferred Resident 1 from the bed to the shower chair alone, instead of following the facility ' s policy to use a two-person physical assist. Resident 1 was being transferred from the bed to a shower chair and during the transfer, Resident 1 slid to the floor. These failures resulted in Resident 1 falling, sustaining bruising of bilateral (both) lower legs (tibula (inner and larger bone) /fibula (the outer and narrower bone)) with fractures (breaks) requiring a transfer to a general acute care hospital (GACH), having pain, and an application of bilateral leg splints (a splint is a device used for support or immobilization of a limb or the spine). CNA 1 did not report Resident 1's accident until two days later, which resulted in a delay in [DIAGNOSES REDACTED]. Findings: On 6/13/16, at 2:07 p.m., during an unannounced visit to the facility, Resident 1 was observed with splints intact to the bilateral lower extremities (BLE). Resident 1 was awake, well groomed, and dressed appropriately. Resident 1 stated she did not remember how she fractured her lower legs. A review of Resident 1's Admission Face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 3/8/16, indicated Resident 1 had memory problems, unclear speech, severely impaired vision, was unable to walk, and was totally dependent on staff for care. Resident 1 required a two-person physical assist for transferring (moving between surfaces including to or from: bed, chair, wheelchair, standing position). According to the MDS; Resident 1 required a one-person physical assist for eating, dressing, toilet use and personal hygiene. Resident 1 had no functional limitation in the range of motion of the upper and lower extremities and used a wheelchair as a mobility device. A review of a plan of care, dated 3/24/14, titled ADL (activity of daily living) self-performance deficit indicated Resident 1 had deficit in activities of daily living. The staff interventions included to assist Resident 1 with transfers using a mechanical aid of a Hoyer lift with a two-person assist. According to the facility's interdisciplinary progress notes, on 6/7/16, at 11:49 a.m., when Resident 1 was being transferred by CNA 1 from the bed to the shower chair, Resident 1 slid down the sling and CNA 1 assisted Resident 1 to the floor. Resident 1 sustained BLE fractures (break) of both bones of the lower leg, tibia/ fibula requiring an application of a BLE cast. According to a nursing note, dated 5/29/16, and timed at 2:51 p.m., two days after Resident 1's fall, written by a licensed vocational nurse (LVN 1), Resident 1 had purple discolorations to the right anterior (nearer the front of the body) lower leg measuring 1.0 centimeters (cm) by 0.5 cm with surrounding light blue discoloration measuring 4.0 cm by 5.0 cm. Resident 1 had BLE pitting edema (the formation of a depression or indentation in living tissue that is produced by pressure with a finger or blunt instrument and disappears only slowly following release of the pressure in some forms of edema) +3 edema (6mm deep and10-12 seconds to rebound (bounce back)). The note indicated Resident 1's pain was 2 on a scale of 0-10 (10 being the worse). Another nurse's note indicated a message was left with Resident 1's physician. The physician called back at 7:04 p.m., with an order to monitor Resident 1. A review of the facility's undated investigation report included a written statement by CNA 1 indicating on 5/27/16, he was transferring Resident 1 from the bed to a shower chair when Resident 1 slid down the standing lift and he assisted her to the floor by putting his two arms on her back. The report indicated that CNA 1 and another CNA 2 did not report the incident to the charge nurse. A review of Resident 1's nursing note, dated 5/31/16, and timed at 11:40 a.m., indicated physician's orders [REDACTED]. A nurses' note, dated 5/31/16, and timed at 4 p.m., indicated Resident 1 was transferred to a (GACH), four days after falling. A review of the GACH's report, dated 6/1/16, at 7:05 p.m., indicated Resident 1 had swelling of the BLEs with tenderness to touch. The GACH's x-rays of the bilateral tibula and fibula bones showed slightly displaced fractures of the bilateral tibiofibular bones with soft tissue swelling. On 6/20/16, at 10:28 a.m., during a telephone interview, CNA 1 stated on 5/27/16, he transferred Resident 1 from the bed to the shower chair by himself. CNA1 stated he assisted the resident to the floor when he noticed she was sliding down the standing Hoyer lift. CNA 1 stated another (CNA 2) came to assist him to transfer Resident 1 from the floor to the shower chair using the Hoyer lift. CNA 1 stated he did not report the incident of Resident 1 falling to the charge nurse and proceeded with showering Resident 1, because she did not complain of any pain or discomfort. CNA 1 stated there was no redness or injury on Resident 1's body. A review of the facility's policy and procedure (P/P) titled, Accident and Incidents-Investigation and Reporting, revised November 2012, indicated that any incident involving residents, employee, or visitors, should be reported to the immediate supervisor as soon as practical. On 6/14/16 at 2:01 p.m., during a telephone interview, the assistant director of nurses (ADON) stated CNA 1 was aware a two-person assist was needed during a resident's transfer. A review of the facility's policy and procedure (P/P) titled, Moving a resident from bed to chair/chair to bed, revised on November 2012, indicated that if a resident cannot stand alone, to use two people one in each side of the resident. Another facility's P/P titled, Lifting machine by mechanical device, revised in November 2012, indicated the facility's staff are to follow the manufacturer's instructions for use of each specific type of lifting machine. The policy stipulated a minimum of two staff members should be used in using a lift machine to reduce the risk of staff or resident ' s injury. A review of CNA 1 personnel file, indicated CNA 1 was hired on 3/9/16 and was terminated on 6/7/16, due to violating established company rules. A review of an Employee Separation Report, indicated CNA 1 failed to follow the facility's policy to have a two-person assist during a transfer, which resulted in a resident's injury (Resident 1). On 6/21/16, at 1:51 p.m., during a telephone interview, the ADON stated CNA1 was terminated for not following the facility's policy and procedure on transferring residents with two people when using a transferring device. The ADON stated CNA1 should have called for help and should not have transferred Resident 1 by himself.

Based on observation, interview, and record review, the facility failed to ensure that three of 30 sampled residents (Residents 11, 14, and 25) and five of 72 randomly selected residents (RSR 74, 77, 79, 80, and 89) received the necessary supervision and adequate use of devices to prevent accidents, falls, and altercations. 1. Resident 14, who was at risk for falls, and had a history of [REDACTED]. The last fall, on 1/18/16, the resident sustained [REDACTED]. 2. Resident 11, who required a two-person physical assist in using a mechanically lift, per the facility's policy, the staff used a one-person assist, which resulted in Resident 11 falling, left arm being caught in the lift's sling, resulting in a left arm fracture (humerus). Resident 11 required a transfer to the GACH and received strong narcotic pain medications of Dilaulid .5 mg and Norco 10/325 milligram (mg). 3. Resident 79 struck Resident 80 with a chair, while not being supervised, resulting in blunt head trauma (BHT) to Resident 80 and a laceration (a deep cut or tear in skin or flesh) requiring a transfer to a GACH and receiving five staples (used in closing large skin wounds) and pain medication. 4. Resident 25, who had a history of [REDACTED]. Resident 25 was placed on one to one monitoring, per the resident's plan of care, which was not implemented by the facility. Due to Resident 25 not being supervised, and the plan of care not being implemented, Resident 25 struck another resident (Resident 74) with his hands, on the back of the Resident 74's head. 5. Resident 77, who was identified by the facility as a high risk for falls and injury, and had a recent fall with blunt head trauma, had a physician's orders [REDACTED]. The pad alarm did not sound when Resident 77 stood up to alert the staff resulted in a fall. As a result of these deficient practices of the facility's staff not supervising the residents, Residents 11, 14, and 77 had falls and Residents 11 and 14's falls resulted in fractures requiring a transfer to a GACH, for an evaluation, pain medications, further treatment and a surgical interventions. Residents 74, 80, and 89 being struck on or about the face/head by other residents, due to the facility's lack of supervision. Findings: 1. During a recertification survey of a locked facility on 4/1/16 at 10:27 a.m., Resident 14 was observed sitting in a wheelchair inside his room. A review of Resident 14's Admission Face Sheet, indicated Resident 14 was admitted to the facility on [DATE] and readmitted from the GACH on 3/21/16. According to the Admission Face Sheet and a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/25/16, Resident 14's [DIAGNOSES REDACTED]. A review of Resident 14's MDS, dated [DATE], indicated Resident 14 had moderate cognitive impairment. Per the MDS, Resident 14 required a non-weight bearing assistance during ambulation to and from any distant areas on the floor. The MDS, dated [DATE], indicated Resident 14 required guided maneuvering during transfers between surfaces (to and from the chair and standing position). Resident 14's nursing care plans did not have specific staff approaches as to how Resident 14 will be supervised when walking. The care plans only focused on the resident's decline in mobility, transfers, and decreased balance and safety awareness, but was documented as Resolved on 1/5/16. A review of the facility's interventions, developed during the interdisciplinary team (IDT) meetings, after each of Resident 14's fall incidents (except 10/2/15), dated 10/20/15, 11/9/15, 11/12/15, and 1/19/16, lacked documentation of an evaluation of prior interventions to address Resident 14's unsteadiness and weakness. On 4/6/16 at 10:40 a.m., during an interview, a registered nurse (RN 2) indicated that the IDT meetings were conducted on residents after each fall incident. RN 2 stated, We do analysis and we do what we could do. RN 2 indicated that they did not conduct an IDT meeting after Resident 14's fall incident on 10/2/15, which was Resident 14's first fall. RN 2 stated, I have no idea why we don't have an IDT for that fall. On 4/6/16 at 11:15 a.m., during an interview, a licensed vocational nurse (LVN 8) indicated that she regularly took care of Resident 14 as a charge nurse. LVN 8 stated that Resident 14 was very confused, required help with showers, was able to walk, but was assessed to be a fall risk with repeated incidents of actual falls. According to LVN 8, His (Resident 14) legs were weak and balance was unstable. LVN 8 stated that in November 2015, there was an incident when Resident 14 had fallen twice in one day, LVN 8 stated the first fall incident happened around 5:30 a.m., on 11/12 /15, before she started her shift at 7 a.m. LVN 8 stated Resident 14 had the second fall on her shift, after breakfast on the same day, on 11/12/15. When LVN 8 was asked whether she implemented additional interventions to prevent Resident 14 from falling the second time on the same day (11/12/15). LVN 8 stated she had instructed Resident 14's certified nursing assistant (CNA) to watch the resident. LVN 8 stated, I told the CNA (CNA 27) that we cannot leave him (Resident 14) by himself. LVN 8 stated, The problem was we didn't have an extra CNA to watch the resident and the CNA (CNA 27) had to help other residents. During an interview on 4/6/16 at 3:45 p.m., a physical therapist (PT 1) indicated that she initially provided rehabilitation (rehab) services for Resident 14 in the month of November 2015, after the fall. PT 1 indicated that due to Resident 14 having dementia, he had difficulty in following instructions and staying on task. PT 1 indicated that Resident 14 had an unsafe gait pattern and required contact guard assist (help with balance by use of hands). PT 1 stated that Resident 14 stopped receiving rehab services on 1/5/16. PT 1 stated that upon Resident 14's discharge from rehab on 1/5/16, he demonstrated independence in ambulation, but still required visual or verbal cues for safety recognition. On 4/7/16 at 9:18 a.m., during a telephone interview, CNA 28 stated Resident 14 had fallen during her shift in January 2016 (1/18/16). According to CNA 28, she was not aware that Resident 14 had gone out to the smoking patio because she was assisting another resident. CNA 28 stated, I have other residents who are total care. CNA 28 stated the charge nurse had informed her that Resident 14 had fallen in the smoking patio and they had done an incident report that time. CNA 28 stated, I was surprised that he (Resident 14) went to the smoking area, because he always just stayed in the dining room. A review of Resident 14's nursing progress notes documented from 10/2/15 through 1/23/16, indicated Resident 14 had fallen five times within three months in the facility as follows: -An entry, dated 10/2/15, and timed at 7:19 p.m., indicated the staff found the resident on the bathroom floor. The resident was found to have an abrasion (an area damaged by scraping or wearing away) on the left knee. -An entry, dated 11/8/15, and timed at 9 p.m., indicated the staff found the resident on the floor outside the bathroom. The resident sustained [REDACTED]. -An entry, dated 11/12/15, and timed at 8:27 a.m., indicated at 5:30 a.m., that day, the resident tried to walk without assistance and fell . The resident sustained [REDACTED]. -An entry, dated 11/12/15, and timed at 9:37 a.m., indicated at 8:50 a.m., that day, the resident tried to walk without assistance and fell . The resident sustained [REDACTED]. -An entry, dated 1/18/16, and timed at 3:20 p.m., indicated at 9:30 a.m., the staff found the resident on the floor by the smoking patio. The resident sustained [REDACTED]. A review of a nursing progress note, dated 1/23/16, and timed at 11:31 a.m., indicated Resident 14 complained of pain on the left hip. A subsequent nursing note, dated 1/23/16, and timed at 7:20 p.m., indicated Resident 14 was sent to the GACH, after an x-ray (left hip) indicated Resident 14 had a fractured (broken bone) left hip. A review of Resident 14's admission note, dated 1/23/16, from the GACH's emergency room , indicated that the primary complaint was a fall and Resident 14 presented with a left hip fracture. A review of Resident 14's history and physical (H&P) report, from the GACH, dated 1/24/16, indicated Resident 14 was admitted to the GACH with a left femoral neck (the shaft of the femur; hip) fracture after suffering a fall at the nursing home. A review of the GACH's operative report, dated 1/28/16, indicated Resident 14 underwent a hemiarthroplasty (a surgical procedure for repair of an injured or diseased hip joint involving replacing the head of the femur (long thigh bone) with a prosthesis(an artificial device to replace a missing or impaired part of the body) procedure of the left hip on 1/27/16. The indication for the surgical procedure was documented as, Mechanical fall, pain in the left hip, inability to walk and x-rays showing a displaced left femoral neck fracture. Resident 14 was readmitted back to the facility on [DATE], after a seven-day stay at the GACH. A review of the facility's policy and procedure titled, Accidents and Incidents- Investigating and Reporting dated November 2012, stipulated that accidents or incidents occurring on facility's premises must be investigated. The procedures indicated that the results of the investigation and pertinent information will be included in the resident's medical record. On 4/7/16 at 12:10 p.m., the administrator and the director of nursing (DON) were unable to provide documentation of the outcome of the facility's investigation regarding Resident 14's fall, that resulted in a fractured hip. 2. During the facility's tour (in the Palm Court Unit), on 3/29/16, at 9 a.m., a licensed vocational nurse (LVN 10) stated a resident (Resident 11) had a history of [REDACTED]. A review of Resident 11's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 11's [DIAGNOSES REDACTED]. (a mental disorder resulting in faulty perception, inappropriate actions and feelings). A review of Resident 11's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/11/15, indicated Resident 11 had a short and long-term memory problems with severely impaired cognitive skills (ability to think and reason) impairment. According to the MDS, Resident 11 required an extensive assistance (resident involved in activity with one staff providing support) with bed mobility, transferring, hygiene, and dressing. Resident 11 was totally dependent in walking, toilet use and personal hygiene and was always incontinent (lack of control) of bowel and bladder, but was not on a bowel program. A review of a Fall Risk Assessments, documented initially on 6/11/10, and last recorded on 7/13/15, indicated Resident 11 was identified as a high risk for falls. According to the assessments, Resident 11's total score was 16 and the assessment indicated a score of 10 or above represented a high risk for fall. During an observation on 3/30/16, at 8:30 a.m., Resident 11 was being transferred to a shower chair by two certified nursing assistants (CNAs 7 and 12) and one occupational therapist (OT). CNA 12 and the OT were assisting Resident 11 to sit-up, while CNA 7 was maneuvering the standing lift. When Resident 11 was in a sitting position, with the feet dangling on the floor, the OT applied the brace on the resident's left arm. Then CNA 12 applied the sling on both arms and the belt to the back. When everything was secured, CNA 12 started to lift Resident 11 to the shower chair, while the OT was standing to the right of Resident 11. CNA 7 was standing and holding onto the back of the shower chair waiting for Resident 11 to placed in a sitting position on the shower chair. On 3/30/16 at 10:20 a.m., during an interview, LVN 10 stated that on 8/10/15, CNA 20 called him and stated that Resident 11 was on the floor. LVN 10 stated he immediately went to Resident 11's room and saw the resident on the floor and holding his left arm. LVN 10 stated he assessed Resident 11, immobilized and applied an ice compress to Resident 11's left arm. LVN 10 stated he asked Resident 11 if he was in pain, but Resident 11 did not respond verbally. LVN 10 stated Resident 11 responded by nodding when he tried to touch Resident 11's left arm, indicating he was in pain. LVN 10 stated that CNA 20 was assisting Resident 11 and cannot remember the other CNA that was in the room. On 3/30/16, at 3:30 p.m., during a subsequent interview, LVN 10 stated there were two CNAs in the room at the time of Resident 11's fall incident, but LVN 10 could not remember the name of CNA 13. LVN 10 stated CNA 13 was helping another resident in the room, while CNA 20 was transferring Resident 11. LVN 10 stated that every time we are using a standing lift a two-person assist was required. On 3/31/16 at 9:10 a.m., during an interview, CNA 20 stated that on the morning of 8/10/15, she and another CNA was transferring Resident 11 to a shower chair using a standing lift. CNA 20 stated she could not remember the other female CNA's name that helped her the day Resident 11 fell , because she was not always assigned in that area. CNA 20 stated when she got Resident 11 in a sitting position, she put the sling on while putting the belt on the back and Resident 11 slid off the bed resting on the floor, positioned on the right side of his body. CNA 20 stated Resident 11's left arm was still hanging on the sling (thus resulting in the left arm fracture). CNA 20 stated that while she was applying the belt to secure Resident 11, CNA 13 turned her back away from Resident 11 to answer a question of another resident in the room. CNA 20 stated she did not wait for CNA 13, because Resident 11 was just sitting down and she had just applied the belt. CNA 20 stated she did not think she needed help at that point. CNA 20 stated after Resident 11 fell , CNA 13 went out to call the charge nurse for help. On 3/31/16 at 9:20 a.m., during an interview, CNA 20 stated that every time the staff used the standing lift, they must always have two people to assist. Which meant a two-person assist from the start to the finish, until the resident was secure and safe. At 10 a.m., on 3/31/16, during an interview, CNA 13 stated that she was just passing by Resident 11's room and entered to assist another resident in the room and helped CNA 20. CNA 13 stated she had her backed turned, while CNA 20 was applying the belt on Resident 11. On 3/31/16 at 10:45 a.m., during an interview, the director of staff and development (DSD) stated that upon being hired all CNAs are in-serviced and trained regarding the standing lift. The DSD stated all CNAs are given the policy titled, Safe Patient Lifting and Repositioning to read and sign, and to do a return demonstration. The DSD stated during the return demonstration she emphasized that every time a standing lift was used a two-person assist or more was required. During a review of the facility's employees files regarding in-service and training of the standing lift. There was no documented evidence, CNA 20 who was hired on 12/16/14, and re-hired on 11/17/15, was given an in-service and training in the years of 2014, 2015, and 2016, of the proper use of the standing lift. At 4/1/16 at 1:30 p.m., during an interview, CNA 20 stated she was given an in-service and training by the rehabilitation staff and the DSD regarding how to transfer a resident using a standing lift, but could not remember when. CNA 20 stated, I think before the incident happened with Resident 11. On 4/1/16 at 1:40 p.m., during an interview, the DSD stated before the staff start to transfer a resident using the standing lift, they should always ask for help. The DSD stated there must be at least two or more to assist. The DSD further stated that there was no point in time when a staff start transferring a resident, using the standing lift, that the staff should leave or lose focus to prevent accident. On 4/4/16 at 2:35 p.m., during an interview, the physical therapist (PT), stated that he does not provide in-service or training regarding the use of the standing lift. The PT stated it was the DSD who provided the training, because it was more of a nursing skill, but stated, We do teach staff regarding safe transfer. A review of Resident 11's clinical record indicated an incident note, dated 8/10/15, and timed at 4:30 p.m., indicated LVN 10 was notified that Resident 11 was on the floor in his room. LVN 10 immediately went to the scene and noted that Resident 11 was lying on his right side and holding his left arm and shoulder area. LVN 10 assisted Resident 11 back to bed using a full body lift, with a two-person assistance. LVN 10, did a further skin assessment and observed yellowish discoloration to Resident 11's left shoulder, with a raised bump on the left arm without any opened area or bleeding noted. The note indicated the left arm was immediately immobilized shoulder and ice compresses were applied. Resident 11 was medicated with Tylenol 650 milligram (mg) given for facial grimacing and shoulder pain . The physician was notified and ordered a stat (immediately) x-ray order, but instead Resident 11 was transferred to the GACH for an evaluation and treatment. A review of the clinical record for Resident 11 GACH's records, dated 8/10/15, and timed at 4:16 p.m., indicated the x-ray results revealed Resident 11 had a comminuted (break or splinter of the bone into more than two fragments) mid-humerus fracture with mild angulation (rotation and loss of alignment). The emergency room 's note further indicated that Resident 11 required a surgery to place a rod in the arm and therefore should be admitted for surgery. A review of Resident 11's GACH record (medication administration record) indicated that Resident 11 was given Dilaudid (injection into the deep muscle to treat moderate to severe pain) and Norco (pain medication) for the following dates: -8/10/15 at 4:52 p.m., Dilaudid 0.5 mg intramuscular IM, right deltoid (muscle forming the rounded contour of the shoulder). -8/11/15 at 8:33 p.m., Norco 10-325 mg one tablet, given orally. -8/12/15 at 8:54 a.m., Norco 10-325 mg one tablet, given orally. -8/13/15 at 5:37 a.m., Norco 10-325 mg one tablet, given orally. -8/13/15 at 5:11 p.m., Norco 10-325 mg one tablet, given orally. A review of an orthopedic surgeon (educated and trained in the [DIAGNOSES REDACTED]. The note indicated the family chose a closed and conservative treatment with a arm sling and splint (a rigid or flexible appliance for fixation of displaced or movable parts). The note indicated the patient may benefit with the use of a Sarmeinto humeral arm cuff (a pre-fabricated foam-lined orthosis designed for the management of a mid-shaft and distal third humeral fractures) and then also the sling. A review of the facility's policy and procedure titled, Lifting Machine By Mechanical Device, dated 11/2012, indicated the facility's staff are to follow the manufacturer's instructions for the use of the lifting machines with a minimum of two staff members used to reduce the risk of staff and residents injury. The policy also stipulated the DSD or (designee ) will provide training regarding the safe and correct use of mechanical lifts (per manufacturers instructions) to nursing staff during the orientation process, and periodically as the need arises, such as new or different equipment acquired. 3a. An entity reported incident (ERI) was reported to the Department of Resident 79 striking Resident 80 with a chair over the head (two randomly selected residents (RSR)). A review of RSR 80's admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 80's [DIAGNOSES REDACTED]. pressure). A review of RSR 80's quarterly Minimum Data Set (MDS), a standardized assessment and screening tool, dated 2/29/16, indicated RSR 80 had memory problems. According to the MDS, Resident 80 required limited assistance from staff with transferring, personal hygiene, and toilet use. On 4/7/16 at 10:30 a.m., RSR 80 was observed awake sitting in a chair with a stapled (five staples) laceration (a deep cut or tear in skin or flesh) at the back of the head. During an interview, as interpreted by a certified nurse assistant (CNA 26), RSR 80 stated that on 4/4/16 at approximately 12 p.m., he was propelling himself in a wheelchair towards the dining room to get ready for lunch. RSR 80 stated RSR 79 suddenly grabbed a chair and hit him at the back of his head for no reason at all. RSR 80 stated that there were no staff present in the dining room at the time of the incident. A review of another physician's orders [REDACTED]. A review of the GACH's records (emergency room (ER)note), dated 4/4/16, indicated Resident 80 was transported to the GACH via ambulance after being assaulted by another resident in a facility. The ER note indicated Resident 80 sustained a three centimeter (cm) scalp laceration to the occipitoparietal (part of skull positioned above the occipital lobe and behind the frontal lobe) area with the resident complaining of constant aching non-radiating pain to back of his head. The wound was cleaned and staples were applied. Resident 80 was transferred back to the facility on [DATE], at 4:46 p.m. A review of RSR 80's untitled plan of care, dated 4/4/16, indicated the resident was physically struck by another resident (RSR 79) at the back of the head with a chair and sustained a laceration on the back of the head. The resident's goal was to have no more episodes of being hit/struck by another resident, and be able to cope with the incident. The staff's interventions included to allow the resident to express feelings and concerns, monitor for episodes of isolation: and to provide safety and monitor the resident's whereabouts. A review of RSR 80's untitled another plan of care, dated 4/4/16, indicated the resident had a laceration on the back of the head, with the goal of RSR 80 being free from signs and symptoms of infections. A review of the physician's orders [REDACTED]. 3b. A review of RSR 79's Admission Facesheet indicated, RSR 79 was admitted to the facility on [DATE], and readmitted last on 3/20/16. RSR's [DIAGNOSES REDACTED]. A review of RSR 79's annual Minimum Data Set (MDS), a standardized assessment and screening tool, dated 1/21/16, indicated RSR 79 had both long and short-term memory problems, was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision-making. According to the MDS, RSR 79 required supervision from staff with transferring, mobility and ambulation, but required only limited assistance from staff with personal hygiene and toilet use. A review of RSR 79's untitled plan of care, dated 3/14/16, indicated the resident had behavioral problems of hitting another resident. The resident's goal was to have no behavior problem of hitting another resident. The staff's interventions included to encourage the resident express feelings appropriately and listen attentively, give medications as ordered, and notify the physician of any significant changes. A review of the physician's orders [REDACTED]. A review of another physician's orders [REDACTED]. A review of a Nursing Home to Hospital Transfer Form, dated 4/4/16, indicated RSR 79 was transferred to a GACH for behavioral symptoms of agitation and psychosis. A review of RSR 79's plan of care, dated 4/4/16, indicated the resident had an actual physical behavior of throwing chairs related to poor impulse control, with a history of harm to others. The goal was for the resident to demonstrate effective coping skills, to not harm self or others, and for the resident to seek out staff/caregiver when agitation occurs. The staff's interventions included to analyze key times, places, circumstances, triggers, and what de-escalates the resident's behavior. On 4/7/16 at 11 a.m., during an interview, CNA 4 stated that on 4/4/16, between the time of 12 to 12:30 p.m., while residents were waiting for their lunch in the Grove's dining room. CNA 4 stated he was coming from the hallway (Grove lobby) to check on the residents and saw RSR 79 sitting on a chair, then suddenly grabbed his chair and hit RSR 80 at the back of his head. CNA 4 further stated that there was no staff present in the dining room during the time of the incident. CNA 4 also stated that he ran to the dining room to intervene and separated the residents. CNA 4 stated both residents were transferred to the GACH, RSR 79 for the management of his behavior and RSR 80 for the treatment of [REDACTED]. On 4/7/16 at 12 p.m., during an interview, a licensed vocational nurse (LVN 15) stated that when she heard of the two residents altercation (RSR 79 and RSR 80), she immediately ran to the dining room. LVN 15 stated she observed that there was no staff present and supervising the residents in the dining room during the time of the altercation. LVN 15 stated the staff were probably busy preparing the other residents for lunch. At 12:30 p.m., on 4/7/16, during an interview, a registered nurse (RN 1) stated, based on her investigation regarding the incident between RSR 79 and RSR 80, there was no staff present supervising the residents in the dining room during the time of the altercation. A review of the facility's policy and procedure, revised in 7/2015, and titled, Abuse Prevention, Investigation and Reporting, indicated to ensure the resident's rights are protected by providing a method for the prevention of any type of resident abuse. The policy further stipulated each resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of property. 4 a. A review of Resident 25's admission record Face Sheet indicated Resident 25 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 25's [DIAGNOSES REDACTED]. A review of Resident 25's Minimum Data Set (MDS), an assessment and care screening tool, dated 3/14/16, indicated Resident 25 usually had the ability to be understood and understand others. A review of Resident 25's untitled care plan, initiated on 11/29/15, and revised on 3/10/16, indicated Resident 25 had a behavior problem of being physically aggressive, as manifested by striking out at another resident (Resident 89), on 11/29/15 at 12:25 p.m., related to a [DIAGNOSES REDACTED]. According to the plan of care, Resident 25 will have a one to one (1:1) monitoring for behavior management to prevent any aggression toward peers. A review of Resident 89's Admission Face Sheet indicated Resident 89 was admitted to the facility on [DATE]. Resident 89's [DIAGNOSES REDACTED]. A review of Resident 89's MDS, dated [DATE], indicated Resident 89 usually had the ability to be understood and understand others. A review of an incident note, dated 11/29/15, and timed at 1:59 p.m., indicated Resident 89 was hit with a closed fist by Resident 25, on the left cheek and mouth area four to five times. As a result of being struck, Resident 89 was bleeding from the left side of his mouth. A review of Resident 25's Interdisciplinary (IDT) progress note, dated 11/29/15, and timed at 3:19 p.m., indicated Resident 25 had a history of [REDACTED]. A review of Resident 89's IDT progress note, dated 11/30/15, and timed at 12:49 p.m., indicated Resident 89 had a small, an abrasion on the left upper lip, requiring 72 hour monitoring and treatment of [REDACTED]. The cut required treatment to the left upper lip for seven days of cleaning with normal saline solution, patting dry, and applying triple antibiotic ointment and leaving it opened to air, per the physician's orders [REDACTED]. On 4/5/16 at 7:30 a.m., during a concurrent interview and record review of Resident 25's care plan, initiated on 11/30/15 and revised on 3/10/16, the licensed vocational nurse (LVN 4) stated the care plan indicated Resident 25 was to have 1:1 monitoring. LVN 4 stated she did not re

Based on observations, interviews, and record review, the facility failed to implement an infection control program that prevents the spread of infection for six of 30 sampled residents (Residents 5, 10, 12, 14, 19, and 24) and 37 of 72 randomly selected residents (RSR 31-35; 37-41; 43-45; 47-50; 52-56; 58-71, and 78). 1. Residents 5, 10, 12, 14 and 36 RSRs for a total of 40 residents, who were symptomatic with rashes and itching, were treated with [MEDICATION NAME], an anti-parasitic used for treatment of [REDACTED].(PHD) policy regarding treatment and prevention of scabies to prevent the spread of the infection. As a result of the facility not following the policies to control scabies, since 1/2015, 40 documented residents contracted rashes with itching and some were treated multiple times with [MEDICATION NAME] and Ivermectin (by mouth anti-parasitic). The facility did not provide [MEDICATION NAME] (to prevent something from occurring) treatment to residents in the same room simultaneously (at the same time) or isolation precautions as stipulated in the policy to control and eradicate the highly contagious skin infection. These deficient practices resulted in residents complaining of rashes with constant itching and scratching and resulted in the spread of the infection and had the potential to affect more residents, staff, and visitors. 2. A certified nursing assistant (CNA 22) failed to clean/disinfect the blood pressure machine and blood pressure (BP) cuff, before and after using it on Resident 19. 3. A licensed vocational nurse used a stethoscope (medical device for auscultation, or listening to the internal sounds of the human body) on Resident 24, which came in contact with the resident's [DEVICE] site (insertion is the placement of a feeding tube through the skin and the stomach wall) and she then put in her pocket without santizing. 4. The facility had 58 beds with material fabric light pull cords, which were used not being cleaned or sanitized. 5. A randomly selected resident, Resident 78's oxygen tubing/canister was not dated, as per the facility's policy. 6. The facility failed to handle, store, and/or process linens and residents' clothes so as to prevent the spread of infection, by failing to store clean and soiled linen/clothes separately, as per the facility's policy. All these deficient practices had the potential to result in cross-contamination from resident to resident, resulting in the spread of infections. Findings: 1. On 3/29/15 at 7:50 a.m., during the facility's initial tour, Resident 5 was observed standing in front of the nursing station complaining of a body rash with itching. Resident 5 was observed asking a licensed vocational nurse (LVN 3) for a skin treatment. In a concurrent interview, LVN 3 stated, She (Resident 5) wants a skin treatment. LVN 3 escorted Resident 5 to her room, which Resident 5 shared with three other residents, to observe Resident 5 ' s skin condition. When LVN 3 was asked if any of Resident 5's roommates had rashes he stated, Yes, one of the roommates (Resident 10), has rashes too. During an observation of Resident 5's rash, there were multiple scattered small pink raised rashes on the back, chest, abdomen and abdominal folds, both inner thighs, and inguinal (groin) area. In a concurrent interview, Resident 5 stated she had the rash for a long time for more than a month and it was not getting better. Resident 5 stated, I get ointments, but it does not get better. According to Resident 5's Admission Face Sheet, Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's [DIAGNOSES REDACTED]. A review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/19/16, indicated Resident 5 had no cognitive (ability to think and reason) impairment and was able to make needs known and understand others. The MDS indicated Resident 5 required limited assistance (resident highly involve in activity) with a one-person assist with personal hygiene. According to a facility's document titled, Interact Change of Condition Evaluation, dated 12/13/15, Resident 5 was assessed with [REDACTED]. On 1/15/16, the report indicated the recurrent scant papular (small, solid, inflamed raised bumps) rash had progressed to the resident ' s generalized body and Resident 5 continued to complain of occasional pruritus. On 3/30/16 at 11:15 a.m., during a concurrent interview and record review, conducted with the assistant director of nursing (ADON), Resident 5's Medication Administration Record (MAR) and physician's orders [REDACTED]. a. [MEDICATION NAME] Cream one (1) percent (%) (a topical medication for temporary relief of minor skin irritations, itching, and rashes) was applied topically on Resident 5's abdomen and lower back rashes, twice a day every morning and evening shift, for 21 days, from 12/13/15 to 12/31/15. b. [MEDICATION NAME]-[MEDICATION NAME] Cream 1% (a topical medication used to treat (fungal or yeast) infection and relieved inflammation and itchiness) was applied topically to Resident 5 ' s abdominal and inguinal (groin) folds rashes every day and evening shift for five days, from 12/31/15 to 1/4/16. c. [MEDICATION NAME]-[MEDICATION NAME] Cream 1% was applied topically every day and evening shift from 1/17/16 to 2/7/16 (21 days). Resident 5 continued to receive the same treatment from 2/13/16 to 2/26/16 (for14 days), and again for another 20 days from 3/9/16 to 3/29/16, for the general body rashes, as ordered by Resident 5 ' s primary physician. d. On 2/18/16, Resident 5 was treated with [MEDICATION NAME] Cream 5 % applied to all skin surfaces from the head to the soles of the feet; between the toes and fingers and left on overnight for 8-14 hours. There was no documented evidence Resident 5 was placed in isolation or that the other three roommates were treated simultaneously (at the same time), as stipulated in the DPH and the facility ' s policy (as confirmed by the infection control nurse (LVN 1)). During a concurrent interview, on the same date and time (3/30/16 at 11:15 a.m.), the ADON stated, The resident (Resident 5) had rashes since December last year (2015), but she was receiving skin treatments. When asked if Resident 5 was seen by a dermatologist (a physician who specialized in skin disease) for evaluation and treatment, since the rashes had not been resolve for four months after multiple treatments, the ADON replied, No, she (Resident 5) did not have a skin scraping (a skin test for mites, eggs, or mite fecal matter and look under a microscope.) and was not seen by the dermatologist. Her (Resident 5) primary physician is not a dermatologist, but he is the one that diagnosed her skin problem and ordered the skin treatments. We cannot do anything if that's what the primary doctor ordered. A review of Resident 5's primary physician's progress notes, dated from December 2015 to April 2016, there was no documented evidence that indicated the reason for repeated treatment of [REDACTED]. There was also no documentation in Resident 5's clinical record that Resident 5 was seen by a dermatologist and or skin scrapings were ordered and done prior to the application of the [MEDICATION NAME] cream to ensure Resident 5 received the medication for the treatment of [REDACTED]. There was no contact precaution signage posted in on Resident 5's room to alert staff and visitors to wear personal protective equipment ((PPE), refers to protective items, such as gloves, and head caps, long sleeve gown, worn to protect the body from contact with infectious/hazardous agents). 2. On 3/29/16 at 2:15 p.m., during a skin observation of Resident 10's skin with a licensed vocational nurse (LVN 11). Resident 10, who was Resident 5's roommate, had multiple dry, dark brown color scaly, and pinkish pimple-like rash on the chest, back, and upper/lower extremities. A review of Resident 10's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 10's [DIAGNOSES REDACTED]. A review of Resident 10's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/7/16, indicated Resident 10 was independent in cognitive skills for daily decision-making, and had no short or long-term memory problems. On 3/30/16, at 2:30 p.m., during an interview, a treatment nurse (LVN 3), stated Resident 10 had develop a generalized body rash on 8/27/15 (over 7 months prior) based on a documented skin monitoring and assessment. LVN 3 stated Resident 10 was seen and examined by Resident 10 ' s primary physician on 8/27/15 at 2:15 p.m., and the primary physician gave an order for [REDACTED]. The physician also ordered a dermatologist consult. On 3/31/16, at 7:25 a.m., during a concurrent interview and observation in the dining area, Resident 10 stated she was transferred to another room and was now in a room by herself. During an interview, LVN 3 stated Resident 10 was seen by the dermatologist on 3/30/16 in the afternoon and a skin scraping (test for scabies) was ordered for Resident 10. LVN 3 stated Resident 10 was placed in isolation. On 3/31/16, at 8 a.m., during a telephone interview, Resident 10's primary physician stated he suspected the resident may have scabies so he referred Resident 10 to be seen by the dermatologist back on 8/27/15 and 11/13/15. At 2:50 p.m., on 3/31/16, during Resident 10's clinical record review with the ADON, the progress notes and skin monitoring assessment indicated Resident 10 was seen and examined by a dermatologist with an order for [REDACTED]. The dermatologist ordered the following: -On 8/27/15, Isolation and [MEDICATION NAME] cream 5% twice, once a week, [MEDICATION NAME] (use to treat itching and swelling) 10 mg by mouth once a day times four weeks and [MEDICATION NAME] (use to treat skin rashes) cream 0.05 % twice a day for four weeks. -On 9/2/15, [MEDICATION NAME] cream 5%, [MEDICATION NAME] cream 0.05% twice a day. -On 9/10/15, [MEDICATION NAME] cream 0.05% twice a day for two weeks. - On 9/16/15, [MEDICATION NAME] cream 0.05% twice a day for two weeks. -On 10/7/15, continue [MEDICATION NAME] cream 0.05% twice a day for rash on the lower back and abdomen, on and off; [MEDICATION NAME] by mouth (use to treat itching) 25 mg once a day for three weeks for pruritus. A review Resident 10's primary physician's progress note and skin monitoring assessment, dated 11/13/15, indicated the primary physician ordered [MEDICATION NAME] Soluspan Suspension (treatment for [REDACTED]. Resident 10 ' s primary physician ordered another dermatologist consult. A further review of Resident 10 ' s skin monitoring assessment, indicated Resident 10 had a general [DIAGNOSES REDACTED]tous (abnormal redness of the skin due to local congestion, as in inflammation) papular body rash with scattered opened areas, lesions with yellow patches of skin surrounding the [DIAGNOSES REDACTED]. On 3/31/16, at 3:15 p.m., during an interview and record review, the ADON stated Resident 10 was not seen by the dermatologist on 11/13/15, as prescribed by the resident ' s primary physician. The ADON stated sometimes the consultant would refused to see the residents because of the lack of insurance coverage, then the ADON stated, I think the dermatologist was on vacation, I do not know why Resident 10 was not seen on 11/13/15. The ADON stated, The resident (Resident 10) was not isolated, on 8/27/15, as ordered by the dermatologist, because Resident 10 was not diagnosed with [REDACTED]. On 4/1/16, a review of Resident 10's diagnostic laboratories results of a skin scraping performed on 3/30/16, after being treated with [MEDICATION NAME] cream several times, indicated the skin scraping was negative for scabies. 3. On 3/31/16 at 2:43 p.m., during an observation, Resident 14 was observed with multiple red spot rashes on both hands, including the fingers,while sitting in a wheelchair in front of the nurses' station. A review of Resident 14's Face Sheet (record of admission) indicated the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 14 [DIAGNOSES REDACTED]. A review of Resident 14's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 2/25/16, indicated the resident was oriented to year only. According to the MDS, Resident 14 required an extensive assistance of a one-person assist with personal hygiene and dressing. A review of a dermatologist progress note, dated 11/4/15, indicated an evaluation of a generalized body rash for Resident 14 that was described as papules excoriated and Resident 14 placed on contact isolation. A review of Resident 14 physician's orders [REDACTED]. A review of Resident 14 physician's orders [REDACTED]. There was no order to place Resident 14 in contact isolation. A review of Resident 14 physician's orders [REDACTED]. A review of Resident 14's general acute care hospital (GACH) physician's orders [REDACTED]. stay. The facility failed to inform the GACH regarding Resident 14's potential risk for having scabies and receiving multiple treatments (four) with [MEDICATION NAME], prior to being hospitilized. A review of Resident 14's physician's orders [REDACTED].m A review of Resident 14's physician's orders [REDACTED]. A review of Resident 14's diagnostic laboratory result of the skin scraping for scabies that was collected on 3/31/16 at 3:35 p.m. The skin scraping results, dated 4/1/16, and timed at 12:16 p.m., indicated scabies present. On 4/1/16 at 1:21 p.m., during an observation, Resident 14 was placed on contact isolation, with an isolation cart outside the door, but remained in the room with the three other roommates (Residents 3, 13 and 59), who were not treated. There was no documented evidence the three other residents in the room had been treated for [REDACTED]. On 4/1/16 at 1:30 p.m., during a concurrent interview and record review, LVN 3 stated Resident 14's generalized rashes were first observed and documented on 10/31/15. LVN 3 stated Resident 14 received an [MEDICATION NAME] treatment on 11/1/15, without a physician's orders [REDACTED]. During a concurrent observation, Resident 14's skin rashes, on the bilateral hands, right forearm, abdomen, and back, had red papules (red skin lesion) all over. LVN 3 stated the rash the resident has now, looked the same and was in the same areas as it was back in 11/2015 (four months prior). On 4/4/16 at 3:40 p.m., during an interview, a treatment nurse (LVN 3) stated he had 106 residents in his unit (Terrance East and West). LVN 3 stated many residents had rashes and received [MEDICATION NAME] treatment, some residents received the treatment many times. LVN 3 stated Resident 14's skin scraping was positive for scabies on 3/30/16, after the survey team questioned the staff about why so many residents had rashes. LVN 3 stated, after being questioned by the survey team, they called the dermatologist to come to evaluate the residents. LVN 3 stated Resident 14 was placed in isolation after the positive scabies diagnosis. LVN 3 was asked if Resident 14's three roommates were treated [MEDICATION NAME] for scabies, LVN 3 stated, No, the residents have to agree to receive the [MEDICATION NAME]. LVN 3 was asked if the residents were asked and informed about the risk of contracting scabies and he stated, No, the residents were not asked or informed. LVN 3 stated they are monitoring the residents to see if they will develop a rash and then they will provide treatment. LVN 3 stated in the past, they would call the resident ' s primary physicians and describe the resident ' s rash and the physicians would sometime order [MEDICATION NAME] to be applied. On 4/5/16 at 7:25 a.m., Resident 14 was observed in a private isolation room, after donning PPEs, Resident 14's rash was observed. The rash was reddish in color with papules on Resident 14's back and chest. Resident 14 stated, It itches, but I have nothing else to do, but scratch. At 10:30 a.m., on 4/5/16, during an interview, a registered nurse (RN) supervisor, (RN 1) stated they called the PHD, and spoke to the PHN nurse supervisor on 4/1/16, after Resident 14 was positive for scabies. She stated some of the [MEDICATION NAME] orders were prescribed by the residents' primary physicians and the others were prescribed by the dermatologist when she would make visits. RN 1 stated some of the residents were prescribed Ivermectin (Oral ivermectin is an effective and cost-comparable alternative to topical agents in the treatment of [REDACTED]. She stated once they contacted the PHD for direction in treating Resident 14 for scabies, they were told it was not reportable since it was only one resident. 4. A review of Resident 12's Admission Face Sheet indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's [DIAGNOSES REDACTED]. (a neurological disorder that targets brain cells that control movement). A review of Resident 12's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/16/15, indicated Resident 12's decision-making and memory was moderately impaired, but Resident 12 only required limited assistance for activities of daily living. On 3/30/16 at 9:30 a.m., during a concurrent record review and interview, LVN 3 stated that Resident 12 had a generalized body rash and was treated with wescort ointment 0.2% (medication used to treat inflammation of the skin caused by a number of conditions such as allergic reactions, inflammation of the skin, or psoriasis-red, (itchy, and scaly patches of abnormal skin)) for four weeks to treat the psoriasis. Resident 12 was treated with [MEDICATION NAME] (a topical medication for the treatment of [REDACTED]. LVN 3 stated Resident 12's rash was due to the resident's liver condition. A review of Resident 12's Order Summary Report (a recapitulation of the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A second order, dated 1/16/16 at 9:57 pm., indicated another order for [MEDICATION NAME] cream ordered for one time application until 1/24/16. A review of Resident 12's Wound Weekly Monitoring/Assessment, dated 1/11/16, indicated an assessment of a general body rash with circular/oval shape and normal surrounding tissue. The wound care treatment notes specified the current treatment of [REDACTED]. Resident 12's Wound Weekly Monitoring/Assessments, dated 1/25/16, 2/2/16, 2/8/16, 2/15/16, 2/22/16, 3/1/16, 3/8/16, and 3/17/16, indicated that Resident 12 had a generalized body rash, described as circular/oval in shape and with edges even, no depth noted. The wound care treatment notes specified the current treatment of [REDACTED]. The record also indicated that Resident 12 denied any pain, discomfort nor pruritus during time of the assessments. A review of an online article, by Medline Plus, titled, [MEDICATION NAME] Topical, indicated [MEDICATION NAME] use can cause numbness or tingling of the skin; rash; and some side effects can be serious, such as, trouble breathing; continued irritation of the skin or scalp area; infected or pus filled areas of the skin or scalp area at https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 7.html 5. On 4/5/16 at 8:25 a.m., during an interview, the facility's infection control nurse (LVN 1) stated since Resident 14's roommates did not have a rash they were not required to treat them. LVN 1 stated although Resident 14 was positive for scabies and had to be isolated, it was not necessary to treat the roommates. LVN 1, who initially was not providing information when she was asked for tracking and surveillance of skin rashes, stated after the survey team questioned the staff about so many residents with rashes on 3/30/16, the dermatologist was called and came performed skin scrapings (test for scabies mites) on five residents (Residents 14, 31, 33, 46, and 69), all were negative, except for Resident 14. LVN 1 stated they treated a lot of residents last year with [MEDICATION NAME] for rashes with itching, but stated neither she nor anyone else at the facility reported all the rashes to the PHD. LVN 1 also stated three of the facility ' s staff member requested to receive [MEDICATION NAME], because they were itching. However, as of that day, the three employees (included laundry staff, housekeeper, and one rehab staff) had not received the [MEDICATION NAME]. On 4/5/16 at 11:25 a.m., during a telephone interview, a public health nurse (PHN) supervisor, from the communicable disease control program, stated the facility's staff called her on 4/1/16, and stated they only had one case of scabies and asked her if it was required to be reported. She (PHN) stated she informed them if it was only one case, it was not required to report. After the PHN was informed of all of the findings and multiple treatments with [MEDICATION NAME], she stated she was not informed about all the other residents with rashes, itching, and receiving [MEDICATION NAME] treatment for [REDACTED]. The PHN stated,Yes, I would have told them if they had two or more suspected cases it should be reported immediately. The PHN further stated it was a major problem and concern that they did not treat Resident 14's roommates once he was identified positive for scabies. The PHN supervisor stated, as she had informed the facility, if they apply [MEDICATION NAME] on a resident with a rash with itching, then they are treating scabies and it should be reported. The PHN stated it is only considered [MEDICATION NAME] when there are no signs/symptoms of scabies. The PHN stated all of Resident 14's roommates and care givers should have been treated [MEDICATION NAME]. She stated since the case seemed serious and the facility was not following the guidelines she had provided them she will open a case and personally come to the facility the next day (4/6/16). The PHN supervisor stated, after looking in the computer, the facility had not reported anything to them since 2011. According to the physician's orders [REDACTED]. Residents [MEDICATION NAME] TX 5 2/18/16 10 8/27/15, 9/2/15, 3/25/16, 3/31/16 12 1/16/16, 1/24/16 14 11/1/15, 11/8/15, 12/30/15, 1/8/16, 3/30/16 31 1/22/16, 3/31/16 32 9/2015; 3/23/16 33 1/16/16, 3/30/16 34 4/13/15, 7/14/15, 7/21/15, 9/17/15, 9/24/15, 11/6/15, 11/13/15 35 4/15/15 37 2/19/15, 2/26/15, 11/2015 38 4/2015 39 3/24/16 40 2/2015 41 9/2015 43 4/3/15, 4/9/15, 10/8/15, 10/15/15, 44 4/23/15, 4/29/15 45 4/17/15, 5/6/15, 9/15/15 47 10/4/15, 10/11/15 48 11/14/15, 11/21/15 49 11/2015 50 12/14/15 52 4/11/16 53 5/2015 54 1/21/15, 1/29/15 55 3/30/15 56 9/2015 58 12/2015 60 1/22/16, 4/11/16 61 1/26/16 62 1/27/16, 2/3/16 63 3/31/16 64 3/31/16 65 1/13/16 66 1/27/16, 2/3/16 67 2/25/16 68 1/22/16 69 3/30/16 70 3/30/16 71 1/7/16 According to the Public Health Department a Guideline titled, Management of Scabies Outbreaks in California Health Care Facilities, dated March 2008, indicated Scabies was a mite transmitted by direct contact with the person's skin. The sign and symptoms can include papules (red raised bumps) on the hand, wrist, elbows, and fold of armpits, female breast or male genitalia. The guidelines indicated in the long term care facility, the lesions may be found on the back and buttocks of the residents. As the infestation progresses, the rash may mimic other dermatological conditions. The guidelines indicated, usually the first indication that a scabies infestation was evolving was complaints of itching and new onset of rash by one or more residents within a period of 5-12 days. Skin scrapping was recommended on at least one symptomatic case. The guideline stipulated the absence of mites, eggs, or fecal pellets on microscopic examination, does not mean the resident does not have scabies. However, a positive skin scrapping should assist the physicians in the development of appropriate therapeutic and [MEDICATION NAME] treatment plans. The guideline also indicated an outbreak was either one confirmed (positive scraping) or at least two clinically suspected cases (residents, staff, volunteers etc.) during a two week period. A review of a letter, dated 4/8/16, addressed to the facility from the PHD/communicable diseases division and signed by a physician titled, Rash/Scabies Outbreak Notification, indicated an outbreak had been identified with specific guidelines provided of how to handle the scabies outbreak to prevent further infections, which stipulated no discharges or admissions until completed. A review of the facility's policy titled, Infection Prevention and Control, dated March 2009, indicated when scabies were suspected, an immediate search for additional cases should be initiated. The policy also stipulated a scabies control program should be developed and approved by the infection control committee and the program should designate a physician, such as the medical director. The policy also indicated the infection control practitioner was responsible for the following: 1. Identification of contacts of symptomatic cases. 2. Prevention of transmission. 3. treatment of [REDACTED]. 4. treatment of [REDACTED]. 5. Post treatment assessment. 6. Assessment failures. On 4/15/16, at 1:30 p.m., during an extended survey, the facility's medical director stated the facility had scabies and he stated he thought the gait belt (a device used to transfer residents from one position to another, or while ambulating residents) used by the staff applied to many residents was a possible mode of transmission of the scabies. 6. On 3/30/16, at 8:20 a.m., prior to a medication pass observation, a licensed vocational nurse (LVN 8) assigned a certified nursing assistant (CNA 22) to take Resident 19's blood pressure. CNA 22 brought and used the blood pressure (B/P) apparatus and blood pressure cuff inside the resident's room, and placed the blood pressure cuff around the resident's arm to obtain Resident 19's blood pressure without cleaning/disinfecting the blood pressure apparatus and blood pressure cuff before and after used on the resident. A review of Resident 19's admission Face Sheet, indicated the resident was readmitted to the facility on [DATE]. Resident 19's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), an assessment and care screening tool, dated 2/17/16, indicated Resident 19 had no long or short-term memory problems, was independent (decisions consistent/reasonable) in cognitive skills for daily decision making, and required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for all activities of daily living (ADLs). A review of a physician's orders [REDACTED]. On 3/30/16 at 10:10 a.m., during an interview, CNA 22 stated that he failed to clean/disinfect with a disinfectant or a sanitizer cloth, the blood pressure apparatus and blood pressure cuff, before and after use for Resident 19 to prevent infection or cross contamination. On 3/30/16 at 10:30 a.m., during an interview, LVN 8 stated that prior to and after taking all resident's blood pressure, the blood pressure apparatus, blood pressure cuff, and stethoscope must be cleansed/disinfect with sanitizer cloth, to prevent infection or cross contamination among residents and staff. A review of the facility's policy and procedure titled General Infection Prevention and Control Equipment Cleaning and Disinfecting, dated 3/2009, indicated that shared patient care equipment

Based on observation, interview and record review, the facility failed to ensure one of 72 randomly selected residents ((RSR) Resident 84) was free of physical abuse by a certified nurse assistant (CNA 5). RSR 84, who had psychiatric (mental illness) conditions with poor memory recall, was struck in the face twice and pushed by CNA 5, as witnessed by the facility's housekeeper (HK 1). This deficient practice resulted in RSR 84 not being free of physical abuse, and put Resident 84 at risk to feel unsafe, insecure, and had the potential for emotional distress and psychological trauma. Findings: On 3/29/16 at 8 a.m., during an unannounced recertification survey, an investigation of an entity report incident (ERI) was conducted regarding RSR 84 being struck by CNA 5. A review of RSR 84's Admission Face Sheet indicated RSR 84 was last admitted to the facility on [DATE]. RSR 84's [DIAGNOSES REDACTED]. in increased blood sugars). A review of RSR 84's Minimum Data Sheet (MDS), a standardized assessment and care screening tool, dated 8/28/15, under Section C, indicated RSR 84's brief interview for mental status (BIMS) was a 10, which indicated RSR 84 was moderately cognitively impaired. According to the MDS, RSR 84 had difficulty in recalling, had inattentiveness and disorganized thinking. The MDS, under Sections D and E, indicated RSR 84 had a depressive mood disorder resulting in the resident feeling down and hopeless. According to the MDS, RSR 84 had the ability to transfer and walk with supervision; required limited to extensive assistance with a one-person physical assist for dressing, eating, toileting, hygiene and bathing. A review of a nurse's progress note, dated 3/20/16, and timed at 1:16 p.m., indicated that a housekeeper (HK 1) had been cleaning RSR 84's bathroom, when she witnessed, on the same day, between the time of 12:30 p.m. and 1 p.m., a certified nurse assistant (CNA 5) push and hit RSR 84. The same nurse's progress note, indicated RSR 84 was assessed with [REDACTED]. On 3/30/16 at 2:50 p.m., during an interview regarding the abuse incident, RSR 84 stated, No one hit me. There were no bruises observed on RSR 84's face. When asked if she was fearful of being at the facility, RSR 84 stated, No. During a concurrent interview, CNA 25 stated he was on duty the day of the incident, but was out on the patio, and did not witness the incident. When CNA 25 was asked about RSR 84's behavior, CNA 25 stated he had no problem with RSR 84, but stated she was always asking for money. On 3/30/16 at approximately 3:30 p.m., during an interview, the administrator (ADM) and the director of nurses (DON) both stated CNA 5 had been terminated due to the substantiated allegation of physically abusing RSR 84. During a telephone interview conducted on 4/5/16 at 12:20 p.m., HK 1 stated she was cleaning RSR 84's bathroom, when she heard a slap and RSR 84 cry out, She's bothering me! HK 1 stated she ran out of the bathroom and witnessed CNA 5 push Resident 84 and hit her twice in the mouth. HK 1 stated, I told the CNA to stop, but she did not care that I was there. I asked the resident (RSR 84) if she was okay and she stated she was. I reported it right away to the registered nurse supervisor (RN 3). A review of CNA 5's employee file, a form titled, Employee Corrective Action Notice, dated 3/29/16, indicated CNA 5 was terminated because of being observed pushing and hitting RSR 84. A review of the facility's investigation of CNA 5's abuse of RSR 84, dated from 3/20/16 through 3/23/16, indicated two residents (RSRs 90 and 91) witnessed CNA 5 hitting RSR 84 on the head prior to the 3/20/16 incidents. When RSRs 90 and 91 were asked why they did not report the incident, RSR 90 stated he did not know and RSR 91 stated she thought it would be a problem. The report indicated RSRs 90 and 91 were asked if they were afraid, they initially answered, maybe, and kind of, respectively. A review of the RSR's MDS, dated [DATE] for RSR 91 and 3/10/16 for RSR 90, indicated both residents cognition and memory were intact. A review of the facility's policy and procedures, dated 3/2013, and titled, Abuse Prevention, Investigation and Reporting, indicated the facility would ensure that all residents have the right to be free from sexual, physical, and mental abuse, corporal punishment from staff and anyone entering the facility.

Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents(Resident A) had the right to be free from verbal and physical abuse by failing to ensure that Resident A was not verbally and physically abused by Resident B, who approached Resident A, called her "[***] " and violently beat and hit her in the face with closed fists because the resident called and requested the CNA (certified nurse assistant) to turn her radio on, in the middle of the night at around 3:00 a.m. As a result, Resident A sustained multiple bruises on the face and a left orbital (facial bone) fracture. Findings: On 10/17/13, at 11:30 a.m., an unannounced visit was made to the facility to investigate a report of Resident A's allegation of verbal and physical abuse perpetrated by Resident B. At 12:30 p.m., a review of the clinical record indicated that Resident A was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. increased susceptibility to fracture), and [MEDICAL CONDITION]. The annual Minimum Data Set (MDS - a standardized assessment and care plan tool), dated 9/21/13, indicated that Resident A had no long/short-term memory problems, was independent in cognitive skills for daily decision-making, was able to make herself understood and able to understand others. The resident was bed bound, required extensive assistance with bed mobility and totally dependent on facility staff for transfers, dressing, eating, toilet use, personal hygiene and bathing. A review of Resident B's clinical record indicated that she was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS - a standardized assessment and care plan tool), dated 7/4/13, indicated that Resident B had long/short-term memory problems, moderately impaired cognitive skills for daily decision-making, usually made herself understood, and usually able to understand others. The resident required limited assistance with dressing, extensive assistance with personal hygiene and bathing, supervision with bed mobility, transfers, locomotion, eating and toilet use. Resident B was also identified with other behavioral symptoms such as: threatening, screaming, cursing others, hitting or scratching herself, pacing, rummaging, throwing or smearing food or body wastes, making disruptive sounds, was easily distracted and had disorganized thinking. These symptoms put others at a significant risk for physical injury. According to the licensed progress notes dated 9/30/13, LVN 1 indicated that at 3:33 a.m., CNA 1 went to Resident A's room to turn her radio on as per the resident's request. As soon as CNA 1 left the room, she heard the resident yelling for help and immediately went back to the room. Upon arrival, CNA 1 witnessed Resident B leaving Resident A's bedside with closed fist and angry face and also attempted to hit the staff. Upon assessment, CNA 1 noted that Resident A had sustained bruises on the face, eye and mouth. CNA 1 shouted for help and other staff members responded. Resident B was removed and taken to Palm Grove Unit. Both Residents A and B were roommates and they were in the room with four other residents. The doctor was notified and an order was given to transfer the resident to the acute hospital. Resident A was picked up by the ambulance and the Sheriff's Department was notified. A review of Med Reach Ambulance service form dated 9/30/13 indicated that Resident A was transferred to an acute hospital emergency room for treatment. A review of the acute hospital emergency department patient care record and the emergency department physician record both indicated, that Resident A sustained a left orbital [MEDICAL CONDITION] as a result of the assault she suffered from her roommate at the nursing facility. The review of the acute hospital's history, physical evaluation and Resident A's CT-Scan (cat scan or computed tomography, a computer that takes x-ray images) indicated that Resident A sustained a left orbital fracture and was intubated on mechanical ventilation. A review of the acute hospital wound assessment data sheet revealed pictures showing swelling and multiple bruises on Resident A's eyes, mouth, and face. In an interview, on 10/22/13, at 10:24 a.m., Resident D stated that Resident B yelled at her and other roommates lots of times when she was in the same room with them as noted in the progress note dated 5/22/12. According to CNA 1 and CNA 2's written declaration statements, both staff turned on Resident A's radio in the middle of the night when all residents, including the resident's roommates were sleeping. (The radio was turned on whenever Resident A requested staff to do so, during the day or at night.) On 10/30/13, at 2:45 p.m., during an interview, Resident A was discharged from the acute hospital, she stated that when she was listening to her radio at night, she heard the footsteps and voice of Resident B as she walked towards her radio and turned it off. She said she immediately called CNA 1 and told her to turn her radio back on because Resident B just turned it off. When CNA 1 left her room, Resident B again walked towards the radio turned it off, and then came to her bed and started to hit her all over her face and head multiple times. Resident A stated she could not stop Resident B because she is visually impaired due to [MEDICAL CONDITION] and unable to use her hands to cover her face in defense. Resident A stated she could feel that Resident B was a big, strong woman and should not have been placed in her room. Resident A stated that the beating was so bad, that she immediately blacked out, but later yelled and CNA 2 came in to stop Resident B. The resident stated she thought she was going to die during the beating. She said she thought her face was "melting away" because she could feel blood running on her face and called a "[***] " and left. On 10/17/13, at 1:30 p.m., Resident C stated during an interview that Resident B was not happy when Resident A's radio was turned on at night. Resident C stated she heard Resident A's voice which sounded as though she was in pain and saw that her face was badly bruised after she was beaten by Resident B. (The facility staff did not admit awareness.) In an interview on the same date (10/17/13) at 2:00 p.m., DAD (director of activity department) stated she was not aware that Resident A's radio was being turned on at night when everyone was sleeping. The DAD stated the night staff should have requested for a head phone for Resident A in order that noise from her radio would not disturb or prevent Resident B and other residents from sleeping at night. On 10/17/13, at 3:05 p.m., the SSD (Social Services Designee) stated during an interview that Resident B exhibited verbal and physical aggressive behavior such as scratching staff member when providing care and yelling at her peers. The SSD stated that on 9/30/13, at approximately 8:30 a.m., she interviewed Resident B right after the incident had occurred and the resident told her that she beat Resident A because the light was on, the radio was too loud, and she could not sleep. A review of Resident B's care plans dated, 6/28/12 and 8/5/12, indicated the resident had behavioral problems that included [MEDICAL CONDITION] and paranoid [MEDICAL CONDITION] manifested by episodes of yelling, threatening, assaulting and striking out at staff and other residents. Resident B also exhibited short attention span and refuses activity invitation. The care plan goal indicated the resident will have no injuries caused to self and others weekly and would be able to participate in activities that suit her mood/behavior concerns. The intervention required facility staff members such as CNAs, Activities, Social Service and Licensed Nursing Staff were to monitor her whereabouts, provide positive interaction with peers, remove the resident from any source of agitation and also monitor for change in mood and behavior activities. A further review of Resident B's intervention description indicated that the facility did not provide the frequency as to how often assigned staff members were to monitor the resident in order to prevent or remove her from any and all sources of agitation. Also there was no written intervention showing how frequently the facility assigned staff members were to monitor Resident B for change in mood and behavior during all shifts. A review of Resident A's plan of care dated 1/20/11, 6/2/12 and 4/1/13, indicated the resident was at risk for impaired visual functioning related to [MEDICAL CONDITION]. The resident has high risk for bleeding, bruising and skin discoloration relative to anticoagulant therapy. The intervention required nursing staff members provide a safe environment and protect the resident from injury. On 11/6/13, at 1:20 p.m., during an interview, LVN 2 stated that in the past, he had witnessed Resident B suddenly got into physical altercation with Resident E and started to pull her shirt without provocation. Resident B yelled at Resident E alleging that she stole her dress. LVN 2 stated that he and another staff member immediately intervened and separated the residents. The voluntary written declaration statement on the incident between Resident B and E provided to the evaluator, indicated that the incident occurred on 5/22/12. A review of the facility's progress note dated 5/22/12, indicated that at 15:30 (3:30 p.m.), Resident B(#5346) was noted assaulting Resident E(#5223) in the hallway. LVN 2(#1515) immediately intervened and separated the two residents. Resident B was observed with increased delusions stating that Resident E stole her dress. In an interview, on 11/8/13, at 1:20 p.m., the RN (registered nurse) supervisor stated Resident B was admitted with behavioral problem and was placed in Palm Grove Unit because this was where residents with aggressive behavior were housed. However, the resident was later transferred to Palm Court Unit (a unit that houses the less aggressive residents), with Resident A in order to make room for a new aggressive resident in Palm Grove Unit. On 11/8/13, at 2:40 p.m., the DON (director of nursing), stated that Resident B had a history of [REDACTED]. The review of the facility's MAR (medication administration record) indicated that Resident B exhibited behavior of irritability episodes up to three times daily, during the day shift, between 8/1/13 and 8/25/13. The facility policy and procedure indicated that "Abuse" of Residents will not be tolerated in the facility at any time. It is the policy of this facility to take every proactive measure to prevent the occurrence of alleged abuse to any resident. Each resident has the right to be free from Verbal, Physical and Mental Abuse. Resident must not be subjected to abuse by anyone including but not limited to other Residents, Facility Staff, Consultants, Staff of other agencies serving resident, Legal Guardians, friends or other individuals.